Team Membership Online Application

First Name: Last Name:

Address:

City: State: Zip Code:

Home Phone: Work Phone:

Cell Phone: Pager:

E-Mail: Housing Information Time at current residence:

Do you (select one): Rent Own

If renting, please fill out information below.

Landlord's Name:

Address:

City: State: Zip Code:

Previous Address

Address:

City: State: Zip Code:

Marital Status

Married: No Yes Name of Spouse:

Number of Dependants: Ages

Additional Information

Your Age: Date of Birth (proof required):

Place of Birth - City: State:

Social Security #:

Are you willing to submit to an annual physical examination by an accredited physician as required by this organization? Yes No

Please list and explain any physical limitations that would prevent you from performing certain tasks. Enter your comments here.

Do you use/consume habit forming drugs or alcohol? Yes No If so, to what extent? Enter your comments here.

Will you be willing to submit to a periodic drug test as required by this organization? Yes No

Have you ever been convicted of a felony? Yes No If so, please explain below. Enter your comments here.

Do you have a valid driver's license? Yes No

Type: State of Issue:

Restrictions:

Has your license ever been suspended or revoked? Yes No If so, please explain below. Enter your comments here.

Have you had any moving traffic violations in the last five (5) years? Yes No If so, please list dates and violations below. Enter your comments here.

Do you have access to dependable transportation? Yes No

Occupation and Experience Information

Occupation:

Employer:

Employer Address:

City: State: Zip Code:

Years with this employer: Shift work?: Yes No

Supervisor's Name and Title:

Supervisor's Phone Number: May We Contact? Yes No

List any previous Fire, Police, Emergency Medical, Emergency Management, Animal Medical or Animal Handling experience: Enter your comments here.

What animals do you have experience handling? Dogs Cats Birds Horses Cows Swine Sheep/Goats Reptiles Other

Do you have any personal pets? Yes No If yes, what kind and how many? Enter your comments here.

Are you uncomfortable handling any certain animals? Yes No If yes, please list. Enter your comments here.

Do you have any phobias of any particluar animals? Yes No If yes, please list. Enter your comments here.

Would you be willing to assist in/or perform euthanasia on an animal if necessary? Yes No

Do you understand that there will be different levels of training required to fill certain positions of the rescue team? If those requirements are not met, you will be unable to participate in given situations to assure your safety, your team members safety and the animal’s safety. Yes No

Do you now have, or have you ever had, a family member in this organization? Yes No

Personal References (Minimum of three, not family and not living with you.) Reference #1

Name: Phone Number:

Address:

City: State: Zip Code:

Relationship: Years Known:

Reference #2

Name: Phone Number:

Address:

City: State: Zip Code:

Relationship: Years Known:

Reference #3

Name: Phone Number:

Address:

City: State: Zip Code:

Relationship: Years Known:

Professional References (Minimum of three) Reference #1

Name: Phone Number:

Address:

City: State: Zip Code:

Business: Years Known:

Reference #2

Name: Phone Number:

Address:

City: State: Zip Code:

Business: Years Known:

Reference #3

Name: Phone Number:

Address:

City: State: Zip Code:

Business: Years Known:

Position

Position applying for: Rescue Team Public Education Fund Raising Abuse Task Force Foster Home Volunteer Support Other

If accepted to probationary status and then to full membership/employment, I affirm that I will abide by the rules, regulations and Constitution & By-Laws of this Organization. I further declare that I will obey the lawful orders of a duly elected/appointed superior, none of which will jeopardize my safety or well-being. Yes No