APPLICATION FOR MEMBERSHIP                                                    PAGE 2

HERBERTSVILLE FIRST AID SQUAD

NAME:                                                                                                                                      

ADDRESS:                                                                                                                                

TELEPHONE NUMBER:                                           PAGERS NUMBER:                            

CELL PHONE NUMBER:                                        FAX NUMBER:                                     

EMAIL ADDRESS:                                                                                                                     

SOCIAL SECURITY NUMBER:                                                                                              

DATE OF BIRTH:                                                                                                                     

DRIVER'S LICENSE NUMBER:                                                                                              

ANY POINTS ON YOUR LICENSE ?                                                                                      

IF SO HOW MANY ?                                                                                                              

EMT EXPIRATION DATE:                                                                                                      

CPR EXPIRATION DATE:                                                                                                      

BASIC FIRST AID EXPIRATION DATE (IF APPLICABLE):                                               

CEVO EXPIRATION DATE:                                                                                                   

OTHER CERTIFICATIONS:                                                                                                   

ARE YOU CURRENTLY, OR HAVE EVER BEEN, A MEMBER OF ANY OTHER FIRST

AID SQUAD OR FIRE COMPANY ?                                                                                   

IF YES, WHAT SQUAD OR FIRE COMPANY ?                                                                   

FOR WHAT PERIOD OF TIME ?                                                                                           

REASON FOR LEAVING ?                                                                                                     

NAME, ADDRESS AND TELEPHONE NUMBER OF CAPTAIN AND PRESIDENT OF

THAT SQUAD OR FIRE COMPANY:                                                                                    

PLEASE ATTACH ALL APPLICABLE CARDS

***PLEASE PROVIDE A LETTER FROM YOUR PREVIOUS FIRST AID SQUAD OR FIRE DEPT. SIGNED BY AN OFFICER OF THE SQUAD*** STATING YOU WERE A MEMBER THERE ON