ࡱ>  +bjbj Hjj,l$^Pv4^;Bp:::::::$|< >::!;!!!4:!:!!`"36 ^ h^446;0;48j?j?6!& FCIVIL AIR PATROL COUNTERDRUG APPLICATION INSTRUCTIONS: Fill in all items. If the answer is "no" or "none", so state. If additional space is needed, use an additional sheet of paper. Form must be typed or computer generated. 1. DATE (MMM/DD/YY):2. CHARTER (I.E., VA123):3. CREW POSITION: FORMTEXT       FORMTEXT       FORMTEXT      4. NAME (LAST/ FIRST/M.I.):5. IF KNOWN BY OTHER NAME, SPECIFY: FORMTEXT       FORMTEXT      6. TYPE APPLICATION:  FORMCHECKBOX  INITIAL  FORMCHECKBOX  RE-CERTIFICATION  FORMCHECKBOX  RE-APPLICATION7. CAPID:8. SSAN:  FORMTEXT       FORMTEXT      9. HOME PHONE:10. BUSINESS PHONE: FORMTEXT       FORMTEXT      11. PLACE OF BIRTH (CITY & STATE):12. DATE OF BIRTH (MMM/DD/YY):13. GENDER:  FORMTEXT       FORMTEXT       FORMCHECKBOX  MALE  FORMCHECKBOX  FEMALE14. DRIVER S LICENSE NUMBER:STATE: FORMTEXT       FORMTEXT      15. LIST RESIDENCES DURING THE LAST 3 YEARS BELOW, IN REVERSE ORDER. BEGIN AT THE TOP WITH YOUR PRESENT ADDRESS. ZIP CODE IS ONLY REQUIRED FOR THE PRESENT ADDRESS. POST OFFICE BOX OR RURAL ROUTE IS NOT ACCEPTABLE.DATES (MMM YY)FROMTONUMBER AND STREETCITYCOUNTYSTATE FORMTEXT      PRESENT FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT ZIP CODE:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      16. HAVE YOU EVER SERVED IN THE U.S. ARMED FORCES (ACTIVE, RESERVE OR NATIONAL GUARD): FORMCHECKBOX  Yes FORMCHECKBOX  No IF YES: FORMCHECKBOX  CURRENTLY SERVING; OR LIST TYPE DISCHARGE: FORMTEXT      17. U.S. CITIZEN (MUST BE A U.S. CITIZEN):  FORMCHECKBOX  YES NATURALIZED:  FORMCHECKBOX  YES CERTIFICATE NO.: FORMTEXT      18. CURRENT EMPLOYER:DATE EMPLOYED (MMM/DD/YY): FORMTEXT       FORMTEXT      FULL EMPLOYER ADDRESS:TYPE OF WORK: FORMTEXT       FORMTEXT      19. DO YOU NOW USE, OR HAVE YOU EVER USED, ANY SUBSTANCES LISTED BELOW OR ANY CONTROLLED SUBSTANCE THAT WAS NOT PRESCRIBED A PHYSICIAN? FORMCHECKBOX  NO FORMCHECKBOX  YES (If YES, list the substance(s) and explain on separate sheet.) FORMCHECKBOX  MARIJUANA FORMCHECKBOX  COCAINE FORMCHECKBOX  HEROIN FORMCHECKBOX  HASHISH FORMCHECKBOX  LSD FORMCHECKBOX  METHAMPHETAMINE FORMCHECKBOX  OTHER SUBSTANCESLIST EACH: FORMTEXT      20. ARRESTS. HAVE YOU EVER BEEN ARRESTED:  FORMCHECKBOX  YES  FORMCHECKBOX  NO; TAKEN INTO CUSTODY  FORMCHECKBOX  YES  FORMCHECKBOX  NO; HELD FOR INVESTIGATION  FORMCHECKBOX  YES  FORMCHECKBOX  NO; QUESTIONED BY ANY LAW ENFORCEMENT AGENCY  FORMCHECKBOX  YES  FORMCHECKBOX  NO. IF YES, A FULL EXPLANATION, INCLUDING DATE(S), REASON AND OUTCOME, ON A SEPARATE PAGE, IS REQUIRED CAP FORM 83, FEB 04 PREVIOUS EDITIONS WILL NOT BE USED OPR/ROUTING: DOS CIVIL AIR PATROL COUNTERDRUG MISSION NONDISCLOSURE AGREEMENT By signing this form I realize that due to my current affiliation with the Drug Enforcement Administration (DEA), Bureau of Immigration and Customs Enforcement (BICE), and the U.S. Forest Service (USFS), I hereby declare that I intend to be governed by and will comply with the following provisions: (1) I understand that unauthorized disclosure of information I may acquire as a Civil Air Patrol counterdrug (CD) mission crew member could place human life in jeopardy, or result in the denial of "due process" to a person or persons who are targets of investigations, or prevent the above listed agencies from effectively discharging their responsibilities. (2) I agree that I will never divulge, publish, or reveal either by word or conduct or by any other means disclose to any unauthorized recipient, any information acquired as part of the performance of my duties as a CD crew member or CD mission coordinator where any such divulgence, publication, revelation or disclosure would be contrary to law, regulation or public policy. (3) I understand unauthorized disclosure could be a violation of Federal law and subject to prosecution as a criminal offense. I accept the above provisions as conditions for my participation in the CAP CD mission. I agree to comply with these provisions both during my tenure in the CAP CD mission and following termination of such tenure. (4) I authorize Law Enforcement Agencies to conduct background checks during the screening process. CIVIL AIR PATROL COUNTERDRUG MISSION STATEMENT OF UNDERSTANDING Pursuant to the Agreement among the Civil Air Patrol, Drug Enforcement Administration, Bureau of Immigration and Customs Enforcement, U.S. Forest Service and the Air Force, I may be asked to assist the Bureau of Immigration and Customs Enforcement, Drug Enforcement Administration, or U.S. Forest Service by providing and operating CAP aircraft for law enforcement officers who will conduct reconnaissance to detect illegal activity. I understand the dangers that may result from these patrol flights, which might put me in close proximity to armed drug traffickers. However, I agree I will neither possess nor use any weapons while on a counterdrug (CD) mission, nor will I physically participate in arrest or detention procedures or search and seizure of evidence. I further understand that due to the sensitive nature of this mission, a security screening of participating CAP member is required, and I further understand that this form will be submitted to the Drug Enforcement Administration (DEA) and the Bureau of Immigration and Customs Enforcement (BICE) as part of their mandatory screening process; that successful screening by these agencies is required before I will be permitted to perform certain volunteer service for these and other federal agencies; that false statements to federal agencies is a criminal offense under Title 18, United States Code, Section 1001; that furnishing the required information is voluntary, but failure to accurately provide complete information may result in denial of clearance and/or termination of Civil Air Patrol membership; and rejection by either DEA or BICE, for any reason, may result in resubmission of my fingerprints to the FBI for membership screening in accordance with CAPR 39-2. that I authorize submission of this form to DEA and BICE.  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'- - ^<--  ' - 2 6g  INITIAL6-2* 2 6z    '- - <r--  ' - 2 6  REH62 2 6< -2 6U  CERTIFICATION626-.63-:6 2 6  )  '- - :^--  ' - 2 g  REH62 2  -2   APPLICATIONO222*62-:6 2   + 2 5  / 2 5  / * 2 5"  / 2 5"  / * 2 5L  / 2 5L  / * 2 5v  / 2 5v  / * 2 5  / 2 5  / * 2 5  / ) 2 5a3 2 5a3 * 2 53 2 53 * 2 53 2 53 * 2 53 2 53 * 2 5 3 2 5 3 * 2 533 )- !x2-- !x2 -- !x2/-- !x2--2  11.H**-%2 z  PLACE OF BIRTH )2*262:.26-6- 2 ! (CITY & STATE)3+///+/+/- 2 + : 2 @  +-2   12.H**-#2 a   DATE OF BIRTH 62-2:.26-6-2   (MMM/DD/YY)O;;;33//@"Arialw@ SQwZw0- 2  :0- 2   0)-2 B13.H**-2   GENDER:\:26626 2 * 0p 2  0 2  0*'- !-- !-- ! -- !e -- !/-- !3-- !-- !-- !-- !-- ! -- !-- !- 2 C  2 C  0* 2 C;  2 C;  0* 2 Ce  2 Ce  0* 2 C  2 C  0* 2 C  2 C  0* 2 C  0) 2 C   2 C   0* 2 C"   2 C"   0* 2 CL   2 CL   0* 2 Cv   2 Cv   0* 2 C   2 C   0* 2 C   0)'- - IK--  ' - 2 C MALE L=2*2'- - I--  ' - 2 C FEMALEL.2=2*2 2 C9 +'- !x@-- !x@ -- !x@-- !x@--2 14.H**-12 z DRIVERS LICENSE NUMBER662262)6262266>226 2 : 2  +2 BSTATE:2-3-2 2 H +- !-- !-- ! -- !E -- !-- !-- !-- !-- !-- !- 2 j  2 j  * 2 j ; 2 j ; * 2 j e 2 j e * 2 j  2 j  * 2 j  2 j  * 2 j  ) 2 j B 2 j B * 2 j l 2 j l * 2 j  2 j  * 2 j  2 j  * 2 j  2 j  * 2 j  )- !xN -- !xN --2 15.H**- 2 y *2 ]LIST RESIDENCES DURING THE LAST 3 YEARS BELOW, IN REVERSE ORDER. BEGIN AT THE TOP WITH YOUR *2-6226266236667:-62*23-*1236222*9J66222623:662622;62..62-:2J-62:67'-t2 : FPRESENT ADDRESS. ZIP CODE IS ONLY REQUIRED FOR THE PRESENT ADDRESS. 262226- 2666222 .2 6:62 2 :6*1 62:6636 .:6 -62 262227- 2666322 -(2 7 #POST OFFICE BOX OR 2:2. :..62 6:2 96'-82 RURAL ROUTE IS NOT ACCEPTABLE.6675.6:6.226:.56722.56.2- 2  +'- ! -- !, -- ! -- ! -- ! -- ! -- ! --2  DATES 62-22-2 (MMM YY);;;//- 2  r * 2   *- ! -- ! -- ! -- ! -- ! -- ! -- ! -- ! -- 2 FROM)047 2  %2 TO)4 2 C O%%2  NUMBER AND STREET)007--0-00-)0,-) 2   O$2 #  CITY0)- 2   O$2 GCOUNTY0400)- 2 G O%2 yKSTATE-),)- 2 QK O$- !k -- !k -- !k -- !k -- !k -- !ek -- !k -- !k -- !k -- !yk -- !k G-- !Vk K-- !k -- !o -- !o -- !o -- !o -- !o -- !o G-- !o -- 2 #   2 #   O' 2 J   2 J   O' 2 q   2 q   O( 2   2   O' 2   2   O( 2   O- 2   O* '- ! -- ! -- ! -- ! -- ! -- !e -- ! -- ! -- ! -- !y -- ! G-- !V K-- ! -- ! -- ! -- ! -- ! -- ! -- ! G-- ! -- 2  2  O' 2 8 2 8 O' 2 _ 2 _ O( 2  2  O' 2  2  O' 2  O(-2 PRESENT/3///4+- 2 4 O+- 2   2   O' 2   2   O' 2   2   O( 2 0  2 0  O' 2 W  2 W  O'- 2 ~  O+-2 #  ZIP CODE:\+/373/ 2   O 2 {   2 {   O' 2   2   O' 2   2   O( 2   2   O' 2   2   O' 2 ?  O(- 2 G 2 G O' 2 "G 2 "G O' 2 IG 2 IG O( 2 qG 2 qG O' 2 G 2 G O'- 2 G O+- 2 yK 2 yK O' 2 K 2 K O' 2 K 2 K O( 2 K 2 K O' 2 K 2 K O'- 2 =K O+- !qw -- !qw -- !qw -- !qw -- !qw -- !qw G-- !qw -- 2   2   O' 2  8 2  8 O' 2  _ 2  _ O( 2   2   O' 2   2   O' 2   O( 2   2   O' 2   2   O' 2  4 2  4 O( 2  \ 2  \ O' 2   2   O' 2   O( 2    2    O' 2    2    O' 2    2    O( 2  0  2  0  O' 2  W  2  W  O' 2  ~  O( 2  #   2  #   O' 2  J   2  J   O' 2  q   2  q   O( 2    2    O' 2    2    O' 2    O( 2  G 2  G O' 2  "G 2  "G O' 2  IG 2  IG O( 2  qG 2  qG O' 2  G 2  G O' 2  G O( 2  yK 2  yK O' 2  K 2  K O' 2  K 2  K O( 2  K 2  K O' 2  K 2  K O' 2  =K O(- ! -- ! -- ! -- ! -- ! -- !e -- ! -- ! -- ! -- !y -- ! G-- !V K-- ! -- ! -- ! -- ! -- ! -- ! -- ! 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G-- ! - 2  2  O' 2 8 2 8 O' 2 _ 2 _ O( 2  2  O' 2  2  O' 2  O( 2  2  O' 2   2   O' 2 4 2 4 O( 2 \ 2 \ O' 2  2  O' 2  O( 2   2   O' 2   2   O' 2   2   O( 2 0  2 0  O' 2 W  2 W  O' 2 ~  O( 2 #   2 #   O' 2 J   2 J   O' 2 q   2 q   O( 2    2    O' 2    2    O' 2    O( 2 G 2 G O' 2 "G 2 "G O' 2 IG 2 IG O( 2 qG 2 qG O' 2 G 2 G O' 2 G O( 2 yK 2 yK O' 2 K 2 K O' 2 K 2 K O( 2 K 2 K O' 2 K 2 K O' 2 =K O(- !t-- !t-- !t-- !t-- !t-- !et-- !t -- !t -- !t-- !yt-- !tG-- !VtK-- !t-- !x-- !x-- !x-- !x -- !x-- !xG-- !x--2 16** 2 e.6- 2 u 6 2  6P2 .HAVE YOU EVER SERVED IN THE U.S. ARMED FORCES 3//..73//.3./3/.33)3/2//3:/3+733./-52  (ACTIVE, RESERVE OR NATIONAL,0',,0,,,0,+4/0,'40,#2  GUARD)73/33- 2 B:6 2 W 6*'CC'- - b)--  ' - 2 2C Yes1*& 2 C *CC'- - b--  ' - 2 C Nos6* 2 AC *- !-- !-- !-- !-- !-- !e-- ! -- ! -- !-- !-- !-- !-- !C-- !G-- !VK-- !-- !-- !-- 2  2 IF YES:+/// 2  &' - '- - J--  ' - F2 S'  CURRENTLY SERVING; OR LIST TYPE DISCHAN666627-*122627::6*2-.122626632   RGE:6:2 2    +- 2    2    * 2 7   2 7   * 2 a   2 a   * 2    2    * 2    2    *- 2    )- !x|-- !x|-t\ -2 Y 17.:**-"2 zY  U.S. CITIZEN 626-.26-/2 Y (MUST BE A U.S. CITIZEN);3/+///3/3++/3-2 Y : Y Y '- - \j&--  ' - 2 sY  YES122 2  Y  )Y ' 2 Y  *Y ''-  2  Y NATURALIZED: 62-662*.26Y Y '- - ^  --  ' - .2 ) Y  YES CERTIFICATE NO.:)122627..62-26: 2 Y  +- 2 # 2 # ' 2 J 2 J ' 2 q 2 q ( 2  2  ' 2  2  '- 2  +- !-- !-- !-- !-- !Y -- !~] -- ! -- ! -- !-- !-- !-- !-- !--2  18.S**-(2 z  CURRENT EMPLOYER:666626-3=2*;126 2   + '- 2 *  DATE EMPLOYED 62-23=2*;226-2   (MMM/DD/YY)O;;;33//- 2  :- 2   *- 2 # '- !x-- !vx-- !xY -- !x] -- !x -- !x -- !x-- !x-- !x-- !|-- !| -- !|-- 2   2   * 2 ;  2 ;  * 2 e  2 e  * 2   2   * 2   2   * 2   ) ' 2 *   2 *   * 2 T   2 T   * 2 ~   2 ~   * 2    2    * 2    2    * 2    )- 2 # '- !x-- !x -- !x--,2  FULL EMPLOYER ADDRESS:.6**2=2*;1262666233 2   * '-2 *  TYPE OF WORK:.122:.J:62- 2    &- !t-- ! t-- !t -- !t -- !t-- !t-- !t-- !x-- !x -- !x-- 2   2   * 2 ;  2 ;  * 2 e  2 e  * 2   2   * 2   2   * 2   ) '- 2 *   2 *   * 2 T   2 T   * 2 ~   2 ~   * 2    2    * 2    2    *- 2    &- !-- ! -- !--2 19.S**-2 zW DO YOU NOW USE, OR HAVE YOU EVER USED, ANY SUBSTANCES LISTED BELOW OR ANY CONTROLLED 6:1:669J622:662221;6222662262712623-26622*3-2623*8J:62616:7-6:**27 2  (P2 x.SUBSTANCE THAT WAS NOT PRESCRIBED A PHYSICIAN?2622-2662-63-J2269-26226622622712636* 2 x=  *- !-- ! -- ! -- ! -- !-- !-- !- 2  *=='- - & --  ' - 2 )= NOS6: 2 = *=-='- - %x--  ' - 2 = YES 122@"Arialw@ QwZw0- 2 =(If @"Arialw@p QwZw0-2 =YES 222- ^2 r7=, list the substance(s) and explain on separate sheet.)d&**&*)&)*%*&)**)&*****&*)***%***- 2 h = 0)- !x-- !x-'-- ^s-- ' - 2 mg  MARIJUANA=36&6262 2 m- *'-- s-- ' - 2 m COCAINE6:6262 2 mz +8 8 '-- sA-- ' - 2 m8  HEROINE626:6 2 m8  + 8  8 '--  ss -- ' - 2 m 8  HASHISH622626 2 m" 8  *, , '--  s -- ' - 2 m  ,  LSD*26 2 m  ,  *, , '--  sh -- ' - #2 m ,  METHAMPHETAMINE=3-63>263-3=62 2 m,  +- !xQ-- !xQ-JJ'-- /^-- ' - %2 gJ OTHER SUBSTANCES):-6262623-27622 2 J +2 | J|LIST EACH:*2-2266 2 J| * 2 |' 2 |' * 2 |' 2 |' * 2  |' 2  |' * 2 - |' 2 - |' * 2 W |' 2 W |' * 2  |' ) 2 Z' *- !x-- !x--2 \20**-I2 _e). ARRESTS. HAVE YOU EVER BEEN ARRESTED: 26622-262221;62226222626622-36'--  eT -- ' - 2 _  YES 123'--  e -- ' - /2 _  NO; TAKEN INTO CUSTODY 6:-22266.:663-:71'-- "e-- ' - 2 _+ YES 122'-- Le-- ' - 2 _U  NO; HELD 6:62*6&2 FOR INVESTIGATION .:66222-:3-:6'-- ,i%-- ' - 2 r YES 122'-- ,P-- ' - ;2   NO; QUESTIONED BY ANY LAW ENFOR6::623-:62631271+0J26.:6 2 8 CEMENT AGENCY 62=27-2:2671'-- ,'-- ' - 2 0 YES 122'-- ,Q -- ' - 2 Z NO.6: 2  )-2 bIF YES, -021-2 _"ZA FULL EXPLANATION, INCLUDING DATE(S), REASON AND OUTCOME, ON A SEPARATE PAGE, IS REQUIRED4-5--211.465-9565-555965-1152519555595.59>1:55112465-12591151:5515- 2 bb +- !A-- !gA-- !AJ-- !.AN-- !A|-- ! A-- !A'-- !vA+-- !A-- !E-- !-- !-- !-- !E-- !-- !-@Times New RomanQwZw0-- 2 ! 0-(2 CAP FORM 83, FEB 04=:83A<G..37<./ 2 P 0"->2 (r"PREVIOUS EDITIONS WILL NOT BE USED2622:6226-;62J*)6:-226227 2 (A  0#2 ()OPR/ROUTING: DOS:266:7-6:6:2- 2 % 0+'-                    ՜.+,D՜.+,@ px  S Harrison, NHQ CAP CDOCivil Air Patrol, Inc.1  CAP Counterdrug Application Title|([coDate completedDocument number@0w<83u  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQSTUVWXYZ[\]^_`abcefghijklmnopqrstuvwxyz{|}~Root Entry F hData R#1Tabledj?WordDocumentHSummaryInformation(TDocumentSummaryInformation8CompObjjObjectPool h h  FMicrosoft Word Document MSWordDocWord.Document.89q