NESAR Application for Membership

 

 

Name ______________________________________________   I am at least 18 yrs of age: _________

 

Address _____________________________City _______________   State ___   Zip ________-______

 

Phones:  Home (        ) ____-________  Cell (        ) _____-________   Work (        ) _____-__________

 

Email _________________________________  Cell Text Email _______________________________

 

Emergency Contact ____________________________________   Phone (        ) ______-___________

 

SAR Interest ______________________   Experience _______________________________________

 

Are you a member of an emergency response agency? _____   If YES, list: _______________________

 

Employer _____________________________________   Phone _____________________  Yrs _____

Can you: Drive a bus or RV? _________   Pilot a small watercraft? _________   Drive an ATV? _______

 

Does your personal vehicle have a tow hitch? ______  Are you comfortable towing a small trailer? _____

 

Are you available: Thursday evenings? ______   Weekends? ______   For  emergency callouts? ______

 

Do you have any health problems or fears that could limit your ability to perform SAR missions? ______

           

If YES, explain: ________________________________________________________________

 

Have you ever been convicted of a crime? ______  If YES, explain: _____________________________

 

List current NESAR members you know: __________________________________________________

 

List three references: Name ____________________________   Phone (        ) ______-__________

 

                                    Name ____________________________   Phone (        ) ______-__________

 

                                    Name ____________________________   Phone (        ) ______-__________

 

I hereby authorize the Northeast Search and Rescue, S.E.R.T., Inc., Membership Committee and/or officers

to investigate all statements and information contained in this application.  I understand misrepresentation or omission of facts may be cause for rejection of this application.   I understand the minimum requirements needed to maintain Active Membership status with NESAR.

 

 

_______________________________________________     Date: ______________

                              Applicant’s Signature

For Membership Committee use only

Date received ___________       Received by ______________

 

Events Attended   1    2    3    4     5    6

 

Membership Date _______________    Unit ID # ________

 

Application Fee rcv’d ___________   Police check rcv’d ____________
 
 

 


              

 

 

 

 

 

 

***  Please attach any emergency response related certificates you may have that are current.  ***