First
Name:
Last Name
Address:
City:
State:
Home Phone:
Cell Phone:
Email Address:
Driver License Number:
State:
Issued Date:
Expiration Date:
Name of your subdivision:
Are
you a member of a crime watch program?
Yes No
If
yes, name of the Watch group
Do
you have any law enforcement, fire/rescue or medical training background? If yes, please describe:
Have
you ever completed a CPR Course? Yes No
Have
you ever completed a First-Aid Course? Yes No
Languages
spoken:
Other information:
All applicants for the North Lauderdale Community Emergency Response
Team will have a background check conducted at no cost to the applicant.
Please
return this form to:
Fire
Chief Kevin R. Bowman
North
Lauderdale, FL 33068