ࡱ> #` bjbj t)! $N4PV, Nb%%%%F&)+3333=3 @ M$OhRRM|,F&F&|,|,M%%4NL0L0L0|,%%3L0|,3L0L0L0%V 0,(L0$1dN0NL0S,SL0SL0L0|,|,|,MM<0|,|,|,N|,|,|,|,  $2JN SENIOR APPLICATION FOR SENIOR MEMBERSHIP IN CIVIL AIR PATROL (Type or print. Chaplains must use CAPF 35.)CHARTER NUMBERSOCIAL SECURITY NUMBER FORMTEXT       FORMTEXT      LAST NAME - FIRST NAME - MIDDLE INITIAL formtext       formtext       formtext   FORMCHECKBOX  MALE  FORMCHECKBOX  FEMALEHEIGHT formtext    WEIGHT formtext    BLOOD TYPE  FORMDROPDOWN DATE OF BIRTH DAY MONTH YEAR  FORMTEXT      MAILING ADDRESS (Number and Street) formtext      APT formtext     CITY  FORMTEXT       STATE formtext   ZIP CODE  FORMTEXT      HOME PHONE  FORMTEXT      Email address (This address may be used to contact you concerning CAP events, special interest items and other membership information)  FORMTEXT      NEXT OF KIN (Name and address)  FORMTEXT        FORMTEXT      RELATIONSHIP:formdropdown PHONE: ( FORMTEXT    )  FORMTEXT      MEMBER MOST RESPONSIBLE FOR YOUR JOINING CAP (OPTIONAL : For recruiting purposes) NAME  FORMTEXT       CAPSN  FORMTEXT       CHARTER #  FORMTEXT       EMPLOYED BY POSITION HELDWORK PHONE: (formtext    ) formtext       MAY WE CALL YOU AT WORK? formdropdown formtext      formtext      EDUCATION (ENTER NUMBER INDICATING YEAR COMPLETED: 9 - 20 or OTHER) GRADE COMPLETED  FORMDROPDOWN  DEGREE RECEIVED formtext      PROFESSION / TEACHING CERTIFICATE formtext      To help us better serve our members, please tell us how you heard about Civil Air Patrol (check all that apply): FORMCHECKBOX  Air Show  FORMCHECKBOX  CAP Member  FORMCHECKBOX  Friend  FORMCHECKBOX  Magazine  FORMCHECKBOX  Family Member FORMCHECKBOX  CAP Exhibit  FORMCHECKBOX  School  FORMCHECKBOX  Radio  FORMCHECKBOX  Television FORMCHECKBOX  Other (please name): formtext      VOLUNTARY STATISTICAL INFORMATION (FOR DEMOGRAPHIC RESEARCH ONLY -- NOT REQUIRED FOR MEMBERSHIP) A: IDENTIFICATION: formcheckbox  WHITE formcheckbox  BLACK (NOT OF HISPANIC ORIGIN) formcheckbox  HISPANIC formcheckbox  ASIAN/PACIFIC ISLANDER formcheckbox  AMERICAN INDIAN/ALASKAN NATIVE B: INCOME formcheckbox  $0-$25,000 formcheckbox  $25,001-$50,000 formcheckbox  $50,001-$75,000 formcheckbox  $75,001-$100,000 formcheckbox  OVER $100,000BACKGROUND INFORMATION A. CITIZENSHIP 1. Are you a citizen of the United States? formdropdown  2. Are you an alien admitted for permanent residence? formdropdown _____ (Must possess current alien registration receipt card (Form I-151 or I-551). B. ARRESTS/CHARGES (WRITE  NONE IF APPROPRIATE) formtext      List on a separate sheet, all arrests or charges regardless of age or whether the record in your case has been sealed, expunged, or otherwise stricken from the court records. You must also include all military courts-martial or non-judicial punishment (Article 15, UCMJ or Captains Mast). Failure to provide all required information may result in your membership application being denied. (Note: You may exclude minor traffic violations unless drugs, alcohol or injury were involved.) C. prior military service (WRITE NONE IF APPROPRIATE)  FORMTEXT        FORMTEXT       formtext        FORMTEXT       Branch of Service Grade Discharge Date Discharge Type D. PRIOR CAP MEMBERSHIP (WRITE  NONE IF APPROPRIATE) from to  FORMCHECKBOX  CADET HIGHEST CADET AWARD EARNED formtext       formtext       formtext       formtext       formcheckbox  SENIOR HIGHEST GRADE EARNED formtext       Old Charter # Was your membership nonrenewed or terminated for cause? formdropdown  If yes, provide details on a separate sheet of paper.In applying for membership in Civil Air Patrol, I hereby execute the oath on the reverse side and understand and agree as follows: (a) To permit CAP to use my Social Security Number in my membership records as an identification number and to obtain background information from any person, corporation, or government agency (local, state, or federal) to be used to determine membership eligibility; (b) that if my membership eligibility is questioned, I will be notified and provided the reasons; (c) that prior to a final decision on my eligibility, I will have an opportunity to submit documentary evidence on my behalf; and (d) that CAP membership is a privilege and not a right and CAPs decision on my membership eligibility is final.APPLICANT SIGNATURE (Must be accompanied by FBI fingerprint card, FD-258) DATE formtext      To be completed by commander or designated representative: I certify that the applicant has been introduced to the Core Values, Ethics Policies, and Safety Policies, and that I have fully reviewed the OATH OF MEMBERSHIP (on reverse) with the potential new member. 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OPPORTUNITIES formcheckbox  ENCAMPMENT STAFF formcheckbox  DISASTER RELIEF COUNSELOR formcheckbox  FLIGHT ENCAMPMENT STAFF formcheckbox  INSTRUCTOR PILOT formcheckbox  SPEAKER formcheckbox  INSTRUCTOR formcheckbox  SEARCH AND RESCUE formcheckbox  LEADERSHIP POSITION formcheckbox  GROUND TEAM formcheckbox  ORIENTATION PILOT formcheckbox  PILOT formcheckbox  SPECIAL ACTIVITIES STAFF formcheckbox  OBSERVER/SCANNER formcheckbox  RADIO COMMUNICATIONS PLEASE LIST ANY OTHER SKILLS OR INTERESTS YOU HAVE WHICH MIGHT BE HELPFUL TO YOUR CAP UNIT. formtext      OATH OF MEMBERSHIP (READ CAREFULLY BEFORE SIGNING) I do solemnly swear (or affirm) that: I understand membership in the Civil Air Patrol is a privilege, not a right, and that membership is on a year-to-year basis subject to recurring renewal by CAP. I further understand failure to meet membership eligibility criteria will result in automatic termination at any time. I voluntarily subscribe to the objectives and purposes of the Civil Air Patrol and agree to be guided by CAP Core Values, Ethics Policies, Constitution & Bylaws, Regulations and all applicable Federal, State, and Local Laws. I understand only the Civil Air Patrol corporate officers are authorized to obligate funds, equipment, or services. I understand the Civil Air Patrol is not liable for loss or damage to my personal property when operated for or by the Civil Air Patrol. I further understand that safety is critical for the protection of all members and protection of CAP resources. I will at all times follow safe practices and take an active role in safety for myself and others. I agree to abide by the decisions of those in authority of the Civil Air Patrol. I certify that all information on this application is presently correct and any false statement may be cause to deny membership. I understand I am obligated to notify the Civil Air Patrol if there are any changes pertaining to the information on the front of this form and further understand that failure to report such changes may be grounds for membership termination. I fully understand that this Oath of Membership is an integral part of this application for senior membership in the Civil Air Patrol and that my signature on the form constitutes evidence of that understanding and agreement to comply with all contents of this Oath of Membership. 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J SandersonCivil Air Patrol, Inc.<! 6Application for Senior Membership in Civil Air Patrol Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abdefghijklmnopqrstuvwxyz{|}~Root Entry F`-Data cG1TableSWordDocumenttSummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q