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Surfside Beach Rescue Squad, Inc.

PO Box 14011

Surfside Beach, South Carolina 2957-4011

 Application for Membership

 Name:_______________________________________________   Phone: __________________________

 Address: _____________________________________________  Date of Birth: _____/______/______

 Age: ______         Height: _____      Weight: _____     Hair: __________  Eyes: __________

 Social Security Number: _____-_____-_______          Marital Status: __________

Highest Grade of School Completed: __________       Date of Completion: __________’

 Name Of School: __________________________________

 Driver’s License Number: _____________________ State: ______        Class:  _________ 

Are you insured?  __________        Type of Policy: ______________________________

 Were you, or are you now, in the armed forces?  _________      What Branch?  ____________

 Dates of Duty ______________________   Current Rank or Discharge Status:  ________________________

List duties in Service including Medical Training: ________________________________________________

 ______________________________________________________________________________________

 _____________________________________________________________________________________

 Current Employer:  ________________________________________  Position Held: __________________________

Supervisors Name:  ________________________________________  Phone Number:   ________________________

Have you been convicted of a crime (Misdemeanor or greater) in the past 10 years?  ____________

 If you have please describe fully.

 _____________________________________________________________________________________

 ______________________________________________________________________________________

 Do have any history of narcotics abuse?  __________________________________________________________________________

 Are you under a doctors care or are you currently taking any medications? _______________________________________________

Do you or have you ever held any type of first aid certificate?  _________________________________________________________

Are you willing to take the first available EMT class?  ____________________________________________________

 Applicants Signature:   _______________________________________________________________

Surfside Membership Application Continued….

 Please list Three (3) references (not former employers or relatives) who will be able to provide recommendations for you.

      1)       _______________________________________________________PHONE_________________________________

2)       _______________________________________________________PHONE_________________________________

3)       _______________________________________________________PHONE_________________________________

Are you applying for:  __________ Active Membership     __________  Auxillary Membership

Please Read and Sign Below

 The facts set forth in my application are true and complete, I understand that if accepted any false statement on this application may result in dismissal.

I also authorize the Surfside Rescue Squad, Inc. to make any investigation of my personal history and financial and credit record through any investigative or credit agencies or bureaus of your choice.

In making this application, I authorize you to make an investigative consumer report whereby information is obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted.  This inquiry, if made, may include information as to my character, general reputation, personal characteristics and mode of living.

 Also, upon becoming a member of this organization, I agree to follow policies, procedures and orders of the Chief, and other officers to the best of my ability.  I further agree to live up to my obligations to the people we serve by being a responsible person and acting as such.  I also agree to be held financially liable or any equipment that I loose or damage due to my negligence.  I further understand that I may be dismissed from the squad if I do not follow the rules and guidelines set forth in this statement and all other directives.  In signing this statement I acknowledge that I fully understand what is written here and agree to abide by it.

Signature of Applicant:  ______________________________________            Date:  ______________________
 

________________________________DO NOT WRITE BELOW THIS LINE_____________________________________

Recommended By:  _____________________________         Date: ___________________________

 Reference Check: 

1)       ____________________________

2)       ____________________________

 3)       ____________________________

 License Check:    _______________________________________

 Investigator Notes:   ____________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________

 ___________________________________________

 Investigator Signature:   ________________________________________         Date: _____________________________