ࡱ> ` bjbj Z    .Tb$4 JJJPJK<*ohLnPRPRPR8STVdMXnnnnnnn$Wqhsdn "fZTTP[[Pn  8S8Sso@^^^<\j 8S 8Sn^fZn^^h0  4j8SL @k-J\.i$`j<o<oj$#t\#tH4j#tV4j,YhiYJ^Y<YwYYYnn^YYYofZfZfZfZ***J***J$       REQUEST FOR OPERATIONAL MISSION SPECIALTY QUALIFICATION CARD, CAP FORM 101, OR SPECIALTY QUALIFICATION TRAINING CARD, CAP FORM 101TNAME (LAST, FIRST, MI)  FORMTEXT        FORMTEXT        FORMTEXT  GRADE  FORMTEXT      CAPID  FORMTEXT      CHARTER NO.  FORMTEXT      ADDRESS (STREET, CITY, STATE, ZIP)  FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      HOME TELEPHONE  FORMTEXT      WORK TELEPHONE  FORMTEXT      PAGE TELEPHONE  FORMTEXT      RADIO CALL  FORMTEXT      CAPF 76 (NO./DATE)  FORMTEXT        FORMTEXT      HEIGHT  FORMTEXT    WEIGHT  FORMTEXT    EYES  FORMDROPDOWN HAIR  FORMDROPDOWN BIRTHDATE (D,M,Y)  FORMTEXT       FORMCHECKBOX  SENIOR  FORMCHECKBOX  CADETAPPLICATION FOR:  FORMCHECKBOX  CAPF 101  FORMCHECKBOX  CAPF 101TEMERGENCY CONTACT NAME  FORMTEXT      PRIMARY PHONE  FORMTEXT      SECONDARY PHONE  FORMTEXT      FAA CERT. NO.  FORMTEXT      FAA MEDICAL (CLASS/DATE)  FORMDROPDOWN   FORMTEXT      CAPF 5 DATE  FORMTEXT      CAPF 91 DATE  FORMTEXT      TOTAL HRS PIC  FORMTEXT      MOUNTAIN CLINIC  FORMTEXT      FAA CERT, RATINGS/LIMITATIONS  FORMTEXT      SPECIALTY RATING(S) REQUESTED PLACE AN "X" OVER THE BLOCK NO. FOR EACH REQUESTED RATING FORMCHECKBOX  INITIAL  FORMCHECKBOX  UPGRADE  FORMCHECKBOX  RENEWAL  FORMCHECKBOX  TRANSFER FORMCHECKBOX  1GENERAL EMERGENCY SERVICES FORMCHECKBOX 14GROUND TEAM LEADER FORMCHECKBOX  2INCIDENT COMMANDER FORMCHECKBOX 15GROUND TEAM MEMBER FORMCHECKBOX  3AGENCY LIAISON FORMCHECKBOX 16URBAN DIRECTION FINDING TEAM FORMCHECKBOX  4OPERATIONS SECTION CHIEF FORMCHECKBOX 17INFORMATION OFFICER FORMCHECKBOX  5PLANNING SECTION CHIEF FORMCHECKBOX 18FLIGHT LINE SUPVERVISOR FORMCHECKBOX  6LOGISTICS SECTION CHIEF FORMCHECKBOX 19FLIGHT LINE MARSHALLER FORMCHECKBOX  7FINANCE/ADMIN SECTION CHIEF FORMCHECKBOX 20COMMUNICATIONS UNIT LEADER  FORMCHECKBOX  8AIR OPERATIONS BRANCH DIRECTOR FORMCHECKBOX 21MISSION RADIO OPERATOR FORMCHECKBOX  9GROUND BRANCH DIRECTOR FORMCHECKBOX 22MISSION SAFETY OFFICER FORMCHECKBOX 10SAR/DR MISSION PILOT FORMCHECKBOX 23LIAISON OFFICER FORMCHECKBOX 11TRANSPORT MISSION PILOT FORMCHECKBOX 24MISSION CHAPLAIN FORMCHECKBOX 12MISSION OBSERVER FORMCHECKBOX 25MISSION STAFF ASSISTANT FORMCHECKBOX 13MISSION SCANNER FORMCHECKBOX 26RADIOLOGICAL MONITOR FORMCHECKBOX 27TECHNICAL SPECIALIST (AS APPROVED BY WING/REGION COMMANDER) SPECIALTY:  FORMTEXT       CAPT 116 COMPLETION DATE:  FORMTEXT      FIRST AID TRAINING / QUALIFICATION:  FORMCHECKBOX  STANDARD DATE EXPIRES: FORMTEXT       STATE DRIVER'S LICENSE NO.  FORMTEXT       CAP DRIVER'S PERMIT (CAPF 75)  FORMTEXT       FORMCHECKBOX  ADVANCED  FORMCHECKBOX  EMT/EMICT/PARAMEDIC  FORMCHECKBOX  CPR DATE EXPIRES: FORMTEXT      CAP MEMBERSHIP EXPIRES  FORMTEXT       PRESENT CAPF 101 EXPIRES  FORMTEXT      ATTACH SUPPORTING DOCUMENTATION IN ACCORDANCE WITH INSTRUCTIONS ON REVERSE.I CERTIFY THAT ALL REQUIRED TRAINING HAS BEEN SATISFACTORILY COMPLETED AND THAT THE MEMBER IS QUALIFIED IN THE SPECIALTY AREAS INDICATED.SIGNATURE OF REQUESTOR  FORMTEXT      DATE  FORMTEXT       TYPED NAME/GRADE OF REQUESTOR  FORMTEXT       SIGNATURE OF UNIT COMMANDER  FORMTEXT      DATE  FORMTEXT      ACTION NO.  FORMTEXT      SIGNATURE OF GROUP COMMANDER  FORMTEXT      DATE  FORMTEXT      ACTION NO.  FORMTEXT      SIGNATURE OF WING/REGION COMMANDER  FORMTEXT      DATE  FORMTEXT      ACTION NO.  FORMTEXT      CAP FORM 100, MAY 01 PREVIOUS EDITIONS WILL NOT BE USED AFTER 31 OCTOBER 2001 OPR/ROUTING: DOS INSTRUCTIONS FOR COMPLETING CAPF 100 Initial qualifications and renewals: For the general emergency services (ES) specialty, submit CAPF 100 along with one copy of the required supporting documentation to the unit commander for the unit commander's signature on the CAPF 101. Units will notify wing headquarters of issuances of CAPFs 101 with the general ES specialty. For initial qualifications (other than the general ES specialty), submit CAPF 100 (original plus two copies) along with one copy of the required supporting documentation through the unit commander to the wing headquarters (or through the region DO to the region commander for region staff personnel in regions issuing specialty qualification cards). For renewals other than Incident Commander and Agency Liaison, submit CAPF 100 along with one copy of the required supporting documentation to the unit commander for the unit commander's signature on the CAPF 101. Units will notify wing headquarters of CAPF 101 renewals. For Incident Commander and Agency Liaison renewals, submit CAPF 100 (original plus two copies) along with one copy of the required supporting documentation through the unit commander to the wing headquarters (or through the region deputy chief of staff [DCS] for operations or emergency services as applicable to the region commander for region staff personnel in regions issuing specialty qualification cards). 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" "D"E"U"V""''Jj"\>F~Ⱦȧ}}}}}uou h70Jjh7Uh30jh30Uhtjh75OJQJU h7CJh7 h75h75OJQJ^Jh7CJOJQJ^Jh7OJQJ^Jh75OJQJ\^Jh7CJOJQJhtjCJOJQJjhaUmHnHujhtjU(!!V"{"~$$^`a$ $@^`akdC$$IfTl4 FD&`'    4 laf4T{""#:] & F # p@ P !hEƀRTF.`hf & F ) p@ P !PEƀRTF.^`P#&%7&C] & F # p@ P !hEƀRTF.`h] & F # p@ P !hEƀRTF.`h7&'~WH & FEƀRTF._ & F & p@ P !hEƀRTF.`hall applicable blocks, do not leave out requested information. Indicate the specialty ratings or training areas (maximum of three training areas at any one time) requested. Use a separate application for CAPF 101 and 101T. Do not combine specialty qualification, upgrade, and/or training requests on the same form. Attach the following supporting documentation as applicable to the ratings (or training areas) requested: All applications: Copy of CAP Test 116 completion records (top of answer sheet) for initial application. Evidence of prerequisite qualifications or training (copy of previously issued CAPF 101 [only if transferring from another wing], course completion certificate, etc.). Evidence of satisfactory completion of required classroom instruction. Required specialty training (copy of endorsed CAPF 101T indicating training received) (initial application for a particular specialty rating only). Evidence of satisfactory completion of continuing education requirements (renewals of particular specialty ratings only). Pilots: Copy of current CAPF 5. Copy of current CAPF 91 (SAR/DR mission pilot only). Evidence of current FAA flight review (copy of logbook page or other record). Ground Team Leaders and Members: Copy of first aid (or equivalent) training certificate. Evidence of satisfactory completion of bloodborne pathogen training (a minimum of two ground members/leaders on each ground must have this training). CAP FORM 100, MAY 01 REVERSE     PAGE \# "'Page: '#' '" Address Line 1 PAGE \# "'Page: '#' '" City PAGE \# "'Page: '#' '" 2-letter STATE PAGE \# "'Page: '#' '" ZIP code (PLUS 4 optional) PAGE \# "'Page: '#' '" Phone number INCLUDE AREA CODE (NO punctuation or spaces!) PAGE \# "'Page: '#' '" Phone number INCLUDE AREA CODE (NO punctuation or spaces!) PAGE \# "'Page: '#' '" Phone number INCLUDE AREA CODE (NO punctuation or spaces!) PAGE \# "'Page: '#' '" CAP Radio call sign (abbreviated) PAGE \# "'Page: '#' '" Enter your ROP card number PAGE \# "'Page: '#' '" Enter full expiration date  only Month and Year displayed PAGE \# "'Page: '#' '" Height in INCHES PAGE \# "'Page: '#' '" Weight in POUNDS PAGE \# "'Page: '#' '" Enter in any date format  display reformatted PAGE \# "'Page: '#' '" FAA Certification number as on pilot license PAGE \# "'Page: '#' '" Class ISSUED PAGE \# "'Page: '#' '" Enter full date  only Month and Year displayed PAGE \# "'Page: '#' '" Enter full date  only Month and Year displayed PAGE \# "'Page: '#' '" Enter full date  only Month and Year displayed PAGE \# "'Page: '#' '" Enter full date  only Month and Year displayed ~ZvJm$H & FEƀRTF.H & FEƀRTF.H & FEƀRTF.JnliJ & F@EƀRTF()`@J & F@EƀRTF()`@J & F EƀRTF.^ l"iJ & F@EƀRTF()`@J & F@EƀRTF()`@J & F@EƀRTF()^@&ViJ & F@EƀRTF()^@J & F@EƀRTF()^@J & F EƀRTF.^ \iJ & FvEƀRTF()^vJ & F EƀRTF.^ J & F@EƀRTF()^@>@BDF !   $a$J & FvEƀRTF()`vH` Nr X 6:<>HJvz|~ʚΚКҚ 6:<>`b :>@B $&(̞ОҞԞ$(*,NP|rt Ġ h70Jjh7Uh7jh70JUZXZ "$htjh30 h70Jjh7Uh7jh70JU ! 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