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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 *
Hair *
Eyes *
Can you leave work for an emergency?
Are you in good physical condition?
List any physical limitations *
Do you have any medical limitations or are you on any prescription medications? *
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?
If yes, explain *
Have you ever been convicted of a sexual offense? *
Have you ever been convicted of animal cruelty? *
Do you have a valid driver's license? *
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
Level of Membership: Reserve
Level of Membership: Junior Reserve
Level of Membership: Auxiliary
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. *