VOLUNTEERS IN POLICE SUPPORT
SEARCH AND RESCUE TEAM APPLICATION
1._____________________________________________________________________
Name Last First Middle Social Security #
2._____________________________________________________________________
Address Street /Apt # City State Zip
3.______________________________________________________________________
Phone number Home Work Cell
4.______________________________________________________________________
Date of Birth Place of Birth Race Sex
5.______________________________________________________________________
Hair Color Eye Color Height Weight
YES ( ) NO ( )
_____________________________________________________________________
United State Citizen If Naturalized- Cert # and Date
7.______________________________________________________________________
Residences Last Five Years (If Different Than Above)
________________________________________________________________________
________________________________________________________________________
8.______________________________________________________________________
In Case of Emergency Notify Relationship Phone#
9.______________________________________________________________________
Doctor to Notify For Emergency Phone#
10._____________________________________________________________________
Please List Any All Specialized Training
11. Please Provide Two Reference’s
Full Name Address Telephone
Full Name Address Telephone #
GENERAL INFORMATION - PLACE AN “X” IN THE PROPER COLUMN
YES NO
Have you any physical defect, handicap, chronic diseases
Or other disabilities that would affect your ability to work
As a volunteer? ____ _____
Have you ever used or experimented with narcotics, drugs,
Marijuana or prescription medicines other than by prescription? _____ _____
Have you ever been arrested, taken into custody, held for
Investigation or charged by any law enforcement agency?
(Omit parking violations) _____ _____
If you own a motor vehicle : _____________________________________________________________________
Year make Tag# State
__________________/_______________/__________/_______________
License # State issued Class Expiration date
Has your license been revoked or suspended in this or any other state? If yes
Please give full information: ______ _______
YES NO
________________________________________________________________________________________________________________________________________________
__________________________ _______________________
Date of Application Applicant’s Signature
________________________
Witness Signature
FOR AGENCY USE ONLY------ DO NOT WRITE BELOW THIS LINE
____________________________________________________________
APPROVED ___________________ BY __________________
REJECTED____________________
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