APPLICATION FOR MEMBERSHIP                                                    PAGE 4

HERBERTSVILLE FIRST AID SQUAD

375 HERBERTSVILLE RD.

732-840-9116

FAX 732-840-3008

CRIMINAL BACKGROUND AND DRIVER LICENSE CHECK

I,                                                     ( PRINT NAME ) GIVE HERBERTSVILLE FIRST AID SQUAD PERMISSION TO PERFORM A CRIMINAL BACKGROUND CHECK AND OBTAIN A DRIVERS ABSTRACT. I UNDERSTAND THE RESULTS OF THE CHECKS MIGHT AFFECT MY APPLICATION AND ACCEPTANCE ON THE FIRST AID SQUAD.

                                                                                            SIGNATURE OF APPLICANT

                                                                                        DATE:                                               

SOCIAL SECURITY NUMBER:                                                                                              

DRIVER'S LICENSE NUMBER:                                                                                              

DATE OF BIRTH:                                                                                                                     

CURRENT ADDRESS: