Membership Application

Name *

Address *

City, State, Zip Code *

Home Phone *

Work Phone *

Cell Phone *

Date of Birth *

Social Security Number *

Occupation *

E Mail address *

Height *

Weight

Hair *

Eyes *

Can you leave work for an emergency?

Yes No

Are you in good physical condition?

Yes No

List any physical limitations *

Do you have any medical limitations or are you on any prescription medications? *

Yes No

If yes, please describe the condition or medications so we may help in an emergency.

Medical insurance *

Have you ever been convicted of a felony?

Yes No

If yes, explain *

Have you ever been convicted of a sexual offense? *

Yes No

Have you ever been convicted of animal cruelty? *

Yes No

Do you have a valid driver's license? *

Yes No

Driver's license number. *

Please list the types of animals you have had experience working with. *

List any certifications you have. *

Level of Membership: Active

Yes No

Level of Membership: Reserve

Yes No

Level of Membership: Junior Reserve

Yes No

Level of Membership: Auxiliary

Yes No

To the best of my knowledge the above information is true and accurate. I understand that any false or misleading information contained on this application could lead to my immediate release. *