Emergency Animal Rescue Membership Application Date of Application___/___/____ Member information: Name___________________________________________________________________ Address________________________________________________________________ City____________ Zip Code______ If San Diego, which area? ______________ Phone (H)__________ (W)__________ Pager__________ E-mail_______________ SS#______-______-_______ Birth Date____-_____-____ Height______ Weight______ Hair_____ Eyes_____ Employer Name & Address________________________________________________ Position__________________ Work Days_______________ Hours______________ Can you leave work for an emergency rescue? Y  N  Will you agree to obtain proper full uniform? Y  N  Will you agree to attend scheduled training? Y  N  Are you in good physical condition? Y  N  List any physical limitations__________________________________________ List any special training or qualifications____________________________ Have you ever been convicted of a felony? Y N Do you have any aliases? Y N      List them here_______________________ Animal Handling Information: Check animals you have experience with Dogs  Cats  Equine  Birds  Livestock  Wildlife  Sea Animals  Exotics  specify: _____________________________________________________ Equipment Available for Rescue Operations: Trailer                     Radio Operator                Vehicle 2 Horse                  Call Sign: ________          Car  4 Horse                  Base Station                    Truck 2WD  4WD  Stock                      CB                                     Winch  Hitch:                                                                       Camper  Bumper                                                                ATV  5th Wheel                                                           Travel Trailer  Driver Lic.#________ Exp.Date__/__/__ Class A? Y  N  Car Lic.#_________ Trailer Lic.#__________ Truck Lic.#______________ Level of Membership: Active  Dues are $24.00/year Reserve  Dues are $12.00/year Junior Reserve  Dues are $12.00/year Auxiliary  Dues are $12.00/year All dues are collected on July 1st of each year. Members joining mid-term will pay pro-rated dues, i.e., $2.00/mo for Active, $1.00/mo for all others. Name of vehicle insurance ________________________________________________ Name of trailer insurance ________________________________________________ Medical Insurance_________________________________________________________  In case of emergency, please notify_______________________________________ Emergency Animal Rescue Membership Waiver  I, ____________________________ (please print full name), as an Emergency Animal Rescue member, assume full financial responsibility for and all bodily injury or death that may occur to me personally upon any Emergency Animal Rescue business whatsoever. I also assume full financial responsibility for any and all damage that may occur to my personal vehicle, trailer or equipment upon any Emergency Animal Rescue business whatsoever. Signature_____________________________ Date________________ Parent or guardian (if minor)______________________________ Mail completed application with dues to: Emergency Animal Rescue P.O. Box 2462 Ramona, Ca. 92065