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Date: ________________________ Received:______________
Completed:_____________
Accepted:______________
I. FULL NAME: Last: ________________________________________
Maiden: ______________________________________
First: ________________________________________
Middle: ______________________________________
Alias/AKA: ___________________________
Name Change: _______________________________________
Date filed: ___________________
Court: ______________________________________________
County: ____________________ City: ________________St: _____
SOCIAL SECURITY NUMBER: ______- ____ - ______
DATE OF BIRTH: ___-___-___ CITY:__________________COUNTY:______________ST______
CURRENT ADDRESS: (No Post Office Boxes)
STREET: _________________________________________________________
CITY: ____________________________________ST: ______ ZIP__________
SINCE: _________________________
TELEPHONE: Home: (____)________________Work: (____)_______________
FAX #: (_____)____________________E-mail: _______________________________
Pager (_____)_________________________Cellular: (____)______________________
HT: ____________ WT: ___________EYES:___________ HAIR:____________
**Provide a minimum of 15 years of previous addresses, use back of application if required,
a Post Office Box can not be accepted***
PRIOR ADDRESS #1:
FROM________________ TO_______________
STREET: _________________________________________________________
CITY: ___________________________________ ST:______ ZIP:__________
COUNTY: _______________________________
PRIOR ADDRESS #2:
FROM___________ TO _____________
STREET__________________________________________________________
CITY: _____________________________________ ST: ______ ZIP:________
COUNTY: ________________________________
PRIOR ADDRESS #3:
FROM___________ TO _____________
STREET__________________________________________________________
CITY: ______________________________________ ST: _______ZIP________
COUNTY: __________________________________
II. PASSPORT, DRIVERS LICENSE & IDENTIFICATION: (Attach copies of all documents)
EXACT PASSPORT NAME: _________________________________________
PASSPORT #: _____________________________EXPIRES: ______________
ISSUE DATE: ______________LOCATION ISSUED: ____________________
DRIVERS LICENSE NUMBER: ___________________________STATE: ____
ISSUED: _____________________ EXPIRES:___________________
III. EMPLOYMENT/HISTORY (check appropriate block)
LAW ENFORCEMENT
FIRE/RESCUE/EMS
SAR TEAM
MILITARY
CURENT EMPLOYER SINCE: _____________________
CURENT EMPLOYING AGENCY: _________________________________________
ADDRESS: _______________________________________________________
CITY: ________________________________ST: _______ ZIP: ___________
MILITARY (CURRENT, FORMER OR RETIRED)
SERVICE NUMBER: ______________________________
BRANCH: _____________________________________________________
LAST RANK: ___________________ PAY GRADE:_______________
DATE OF RANK: ________________________________________________
DATE ENTERED ACTIVE DUTY: _______________________
DATE SEPARATED: __________________________________
TYPE/CHARACTER OF SERVICE/DISCHARGE:___________________________
DUTY ASSIGNMENT (MOS): ______________________________________
LAST POSTING LOCATION: _____________________________________________
UNIT OF ASSIGNMENT: _________________________________________________
PREVIOUS SAR TEAM INFORMATION:
MEMBER FROM:__________ TO:___________ POSITION:___________________
TEAM/ORGANIZATION NAME:_________________________________________
ADDRESS:____________________________________________________________
CITY:_____________________________________STATE:_____ ZIP:_________
TEAM LEADER NAME:_______________________________________________
CONTACT NUMBERS: (_____) _________________________________
E-MAIL ADDRESS:____________________ WEB PAGE:_____________________
PREVIOUS EMPLOYER #1:
FROM: __________________ TO:____________________
NAME: ___________________________________________________________
ADDRESS: ________________________________________________________
CITY: __________________________________ST:_______ ZIP:_____________
TELEPHONE : (_______)_________________________________
PREVIOUS EMPLOYER #2:
FROM: __________________ TO:____________________
NAME: ___________________________________________________________
ADDRESS: _______________________________________________________
CITY: _________________________________ST: ______ ZIP:_____________
TELEPHONE : (_______)_________________________________
VI. EDUCATION INFORMATION:
HIGH SCHOOL:
NAME: ______________________________________________________
CITY: _________________________________________ ST: ___ZIP_______
ATTENDED FROM: ___________________GRADUATED: ______________
COLLEGE:
NAME: _________________________________________________________
MAJOR: _______________________________DEGREE: ________________
FROM: ____________________ TO: ___________________
CITY: _________________________________________ ST: ___ZIP_______
COLLEGE:
NAME: ________________________________________________________
MAJOR: _____________________________ DEGREE: _________________
FROM: ____________________ TO: _____________________
CITY: ________________________________________ ST: ____ZIP_______
V. EMERGENCY CONTACT: ________________________________________
RELATIONSHIP: _________________________
ADDRESS: _______________________________________________________
CITY: ________________________________________ ST:_____ZIP _______
TELEPHONE #: (_______)____________________________
ALTERNATE # (________) ___________________________
ALTERNATE #: (_______) ____________________________
NEAREST RELATIVE:
RELATIONSHIP: ____________________
NAME: ________________________________________________________
ADDRESS: _____________________________________________________
CITY: _____________________________ ST:______ ZIP:_________
TELEPHONE #: (________) ________________________________
VI. IMMUNIZATIONS: (mark/indicate date & attach shot records)
[ ] Hepatitis B: #1______________; #2_______________;#3________________
[ ] Hepatitis A: #1_________________; #2_________________
[ ] Tetanus:______________________
[ ] Typhoid:_____________________
[ ] Polio (OPV):__________________
[ ] Cholera:______________________
[ ] MMR:_______________________
[ ] Yellow Fever:________________________
[ ] Meningitis:__________________________
VII. MEDICAL DATA: (Information used only for emergencies)
BLOOD TYPE: ____________________
MEDICAL LIMITATIONS: _________________________________________
MEDICATIONS TAKEN REGULARLY: ______________________________
ALLERGIES/MEDICINAL REACTIONS: _____________________________
PERSONAL PHYSICIAN: __________________________________________
TELEPHONE NUMBER: ___________________________________________
VIII EMERGENCY RESPONSE QUALIFICATIONS: (attach copies)
NASAR SAR TECHNICIAN III
NASAR SAR TECHNICIAN II
NASAR SAR TECHNICIAN I/CREW LEADER
MEDICAL FIRST RESPONDER (40 HOUR DOT)
EMERGENCY MEDICAL TECHNICIAN-BASIC
EMERGENCY MEDICAL TECHNICIAN- INTERMEDIATE
EMERGENCY MEDICAL TECHNICIAN- PARAMEDIC
REGISTERED NURSE OR L.P.N.
MEDICAL DOCTOR
LICENSED AMATEUR RADIO OPERATOR
SAR CANINE HANDLER
TECHNICAL SEARCH SPECIALIST
SEARCH MANAGEMENT CERTIFIED
HAZMAT TRAINING/CERTIFICATION
TECHNICAL ROPE RESCUE (CERTIFIED)
RAPPEL MASTER (CERTIFIED)
SWIFT WATER RESCUE (CERTIFIED)
DIVE RESCUE SPECIALIST (CERTIFIED)
AVAILABLE TO DEPLOY INTERNATIONALLY
XI LANGUAGE SKILLS: (speak, read. write)
[] ENGLISH
[] SPANISH
[] FRENCH
[] CREOLE
[] OTHER_____________
X APPLICANT BACKGROUND
1. Have you ever been arrested for any crime? Yes _____ No _____
If Yes provide:
Date: _______________
Charge: ____________________________________
Arresting agency: _______________________________________
Case #: __________________________
County: ____________________________ State: _________
Disposition: ______________________________________________
2. Have you ever had a criminal case expunged or sealed? Yes _____ No _____
If yes provide:
Date: ______________
Charge: ___________________________________
Court: ________________________________ Case #:_________________
Arresting agency: ______________________________________
Disposition: ______________________________________________
3. Have you ever received military discipline more serious than an Article 15,
non judicial punishment? Yes _____ No _____
If Yes provide:
Date: ______________
Charge: ____________________________________
Agency: _______________________________________________
Disposition: _______________________________________________
4. Have you completed this application providing complete and accurate information
to the best of your knowledge?
Yes: _____ No _____
I affirm or swear that all of the information contained in this application and all attachments to it are
true and correct to the best of my knowledge.
______________________________, ___________
Applicant Signature
COUNTY OF: ___________________
STATE OF FLORIDA
Sworn to and subscribed before me this ______ day of _____________, ______. The person who has come before
me has provided a _____ State Drivers License, number __________________as proof of identity.
____________________________________Notary Public Affix Seal/Stamp
Commission expires:________________
*NOTE: Attach clear photocopies of all documents to this application to include at a minimum the
following. The original of each must also be presented for inspection at the time of application:
1. State issued Motor Vehicle Drivers License
2. Birth certificate with raised seal
3. Current Military issued Identification Card if active duty or Retired
4. Military Separation Form (DD214, Member 4 copy)
5. Most recent U.S. Passport
6. Four current (6 months) 2"X2" color photographs
7. High School and/or College Diploma
8. Copies of all certifications checked off on this application
Florida Special Response Team-A, Inc. provides search and rescue and disaster response assistance to local, county, state and federal agencies along with the governments of other countries.
Due to this responsibility we must complete a through background investigation of all applicants.
Please ensure that you complete all blanks. Incomplete applications will not be processed.
I affirm or swear that all of the information contained in this application and all attachments to it are true and correct to the best of my knowledge. In connection with this membership application I understand that public records, consumer reports or investigative consumer reports which may contain public record information may be requested or made on me which could include:
Further I understand and authorize for this information to be requested from various Federal, State, Local and other agencies which contain my past activities. Florida Special Response Team-A, Inc. has my authorization to up-date this information as needed for official purposes.
I understand that Florida Special Response Team-A, Inc. is a qualified entity under the National Child Protection Act of 1993, as amended and that under s943.0542, Florida Statutes a criminal history check will be run on me by the Florida Department of Law Enforcement and the Federal Bureau of Investigation. Furthermore that this criminal history background check will be based on my fingerprints and the information that I have provided.
Under s943.0542, Florida Statutes any information located under this criminal history check is not considered to be public information and will not be made available as a public record.
Printed Name: ________________________________, DOB: ____________SS#: ______________________
______________________________, ___________
Applicant Signature
COUNTY OF: _____________________________________/STATE OF FLORIDA
Sworn or affirmed to and subscribed before me this ______ day of _____________, _______. The person who has come before me has provided a _____ State Drivers License, number _____________________as proof of identity.
____________________________________________Notary Public AffixSeal/StampCommission Expires:________________
I ____________________________________ do hereby request membership into Florida Special Response Team-A, Inc. a Not-For-Profit, Florida corporation comprised of volunteer (non-paid professional) personnel. I understand that membership is a privilege and not a right. I agree to abide by all of the organization by-laws, rules and safety procedures. I understand that my membership can be terminated at any time for the violation of by-laws or rules and any willful or repeated violations of safety procedures.
I understand that search and rescue work and its required training has inherent dangers. I understand that search and rescue operations and its training may include, but not be limited to, working in, around and/or with helicopters, fixed wing aircraft, high angles and elevations, canine search, mountain search, medical response, SCUBA response and any other activities as required to fulfill the search and rescue mission. I understand and acknowledge that Florida Special Response Team-A, Inc. does not provide medical insurance coverage, workman’s compensation or any other form of liability or medical insurance coverage for myself, my family, my vehicles, personal property or canine.
Knowing this, I agree for myself, my heirs and assigns to hold harmless Florida Special Response Team-A, Inc. its officers, team leaders, instructors and all members. I also agree for myself, my heirs and assigns to hold harmless any corporation, company, organization, group or individual who provides any resource, training facilitation or assistance requested by Florida Special Response Team-A, Inc. as authorized by law.
Signed this _____ day of _____________________, ________.
Applicant Signature__________________________________________
COUNTY OF_______________________
STATE OF FLORIDA
Sworn or affirmed to and subscribed before me this ______ day of ________________, _______. The person who has come before me has provided a _______ State Drivers License number ______________________ as proof of identity.
____________________________________Notary Public Affix Seal/Stamp
Commission expires:__________________