Full Text
APPLICATION FOR MEMBERSHIP - McLEAN COUNTY EMERGENCY MANAGEMENT AGENCY Name Address City Zip Date of Birth Home Phone Social Security No. LEAVE BLANK Age Height Weight Eyes Hair Sex Phone # Marital Status: Single Married Divorced Widowed Number of Dependents: Ages of Each Present Employer Address City Working Hours: A.M. P.M. Business Phone Ext. Nature of Work Are you able to leave work if called? Previous Employer Nature of Work List two references (other than former employers or relatives) NAME ADDRESS PHONE 1. 2. Do you hold a valid driver's license? YES NO State Number Do you have a Amateur Radio License? YES NO Others: RACES AREC MARS Time that you can be reached by radio: A.M. P.M. on MHz. Base Frequency Mobile Frequency Call Letters List all skills and knowledge that would be of value in Emergency Situations that you now possess. List all EMERGENCY EQUIPMENT you possess: 4-Wheel Drive Vehicle Snowmobile Generator Tents Cots Search Lights Chain Saws Others Police Record over the past ten years (excluding minor traffic offenses) OATH REQUIRED OF E.M.A. PERSONNEL I, , do solemnly swear (or affirm) that I will support and defend and bear true faith and allegiance to the Constitution of the United States and the Constitution of the State of Illinois, and territory, institutions, and facilities thereof, both public and private, against all enemies, foreign and domestic; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I further swear (or affirm) that I do not advocate, nor am I, nor have I been a member of any political party or organization that advocates the overthrow of the government of the United States or of this State by force or violence; and that during such time as I am affiliated with the McLean County Emergency Management Agency, I will not advocate, nor become a member of any political party or organization that advocates the overthrow of the Government of the United States, or of this State by force or violence. DATED SIGNATURE Date Accepted E.M.A. Director