Application

Rockland SAR

Membership Application
Rockland Search And Rescue requires this form to be completely filled out and verified. Information listed on this form may be forwarded to Law Enforcement officials if applicable.
Position Applying For*

ATV UnitMarine UnitAerial UnitScuba UnitK9 UnitSupport Volunteer

General Information
General Information
Full Name*

First NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address*
Cell Phone Number*

Area CodePhone Number
Cell Phone Provider*
This is we can subscribe your # to our text message based alert system
Cell Phone "Other" Provider
Alternate Number (Home/Work)

Area CodePhone Number
Current Employer*
Current Employer Info*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Name of Supervisor*
Normal Work Schedule

Personal Information
Personal Information
Social Security Number*
Birth Date*

MonthDayYear
State of License*
Drivers License Number*
CDL?*

YesNo
Height*
Weight*
Eye Color*
Hair Color*
Don't tell me, "I have none..."
Blood Type*
Leave "not sure" if unkown

Emergency Contact(s)
Emergency Contact(s)
Full Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Relation to Volunteer*
Add another?

Option 1Option 2Option 3
Full Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Relation to Volunteer*

Education History
Education History
Do you have either a Highschool Diploma or GED?*

YesNo
Schools or Training?
Special Qualifications

Work History
Work History
1. Name of Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number of Supervisor

Area CodePhone Number
Jobs/Duties Performed
Reason for Leaving
2. Name of Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number of Supervisor

Area CodePhone Number
Job/Duties Performed
Reason for Leaving
3. Name of Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number of Supervisor

Area CodePhone Number
Job/Duties Performed
Reason for Leaving

Prior Residences
Prior Residences for 10 years
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Health & Background
Health & Background
Searchers are required to be in at least good physical shape in order to participate in physical searches away from command center. IMPORTANT - This could be lifesaving information.

This information will be kept confidential.
Your current health condition*

FairGoodExcellent
Do you have any medical conditions or medications that would prevent you from your duties for the position you are applying for? If yes, please explain.*

YesNo
Please explain

References
1. List your References
Please list two persons who are not related to you and who have definite knowledge of your qualifications or fitness for membership. Do not use names of supervisors you listed above as we consider them references, unless otherwise noted.
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
2. Criminal History
Have you ever been convicted of a felony? If yes, please explain*

YesNo
If yes, list date of offense, all charges for which you were convicted and the disposition.
Have you ever been convicted of a crime against a child, family violence or moral turpitude? If yes, please explain*

YesNo
If yes, list date of offense, all charges for which you were convicted and the disposition.

Equipment
Equipment

Check off any (and all) equipment available for use in the event of a search, rescue or recovery. Please note, only select items you own or have ready access to in short notice.

	Yes
ATV
UTV
Pickup Truck
Plane
Boat
Helicopter
Trailer (covered/uncovered)
Generator
Light-tower
Chainsaw
Water/Trash Pump
Radios (UHF/VHF/HAM)
Repeater Radio
Drone/UAV (if yes, please contact via email)
Sonar (side scan/imaging)
FLIR (Infrared)
K9 (rescue or track)
Horse(s)

Certifications
I affirm that the information contained in this application is true and correct to the best of myknowledge, information, and belief. If I am accepted into membership, I understand that I may be required to undergo a medical examination as necessary to determine my fitness for duty. I realizethat any falsification in this application constitutes grounds for rejection or termination from membership. In this regard, and unless I have indicated otherwise below, I authorize my present and past employers to cooperate with Rockland SAR Inc. (RSAR) through its membership committee and to release, on a confidential basis, any information regarding my employment records. I understand that all of the information given will be considered in reviewing myapplication and is subject to investigation. If accepted for membership, I agree to abide by the RSAR By-Laws and any rules and regulations which may apply. I further understand that my membership may be terminated at any time for any reason as provided by RSAR, the By-Laws, rules and/or regulations.
Enter your full name which signifies your understanding and approval of the above statement.*
Today's Date

MonthDayYearHourMinutesAM/PM Option

Authorization for Release of Information
I authorize Rockland SAR Inc. (RSAR) to conduct an investigation into my background, including but not limited to any record of Criminal Arrests which may exist, and to the release to RSAR and all information obtained as a result of such investigation.
Enter your full name which signifies your understanding and approval of the above statement.*
Today's Date

MonthDayYearHourMinutesAM/PM Option
I further understand that this investigation will be confidential and findings contrary to the information provided on the application may subject me to future ineligibility. I understand that the information will be released to the appropriate officers of Rockland SAR Inc. when the investigation is completed.

I verify that the information setforth in this application is true and correct. I understand that any falsification contained in this application shall result in denial or termination of membership.
Enter your full name which signifies your understanding and approval of the above statement.*
Today's Date

MonthDayYearHourMinutesAM/PM Option

Finish
Please upload the appropriate documents to the sections below. Then, enter the captcha and submit this form.
State Issued Photo ID*

Upload a File

Cancelof
Auto Registration

Upload a File

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ATV/Boat Registration

Upload a File

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Headshot of Self*

Upload a File

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Enter the message as it's shown*

Application/Membership Fee*

Membership Fee($125.00 for the first year then,$100.00 for each year)

Enter coupon

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

General Information

Personal Information

Emergency Contact(s)

Education History

Work History

Prior Residences for 10 years

Health & Background

1. List your References

2. Criminal History

Qualification(s)

Equipment