First & Last Name :  Date:  

Street Address:  

Street Address 2: 

City:    State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY   Zip Code: 

E-Mail: 

Day Telephone:   Night Telephone: 

Pager:    Cell Phone: 

SS Number:    Date of birth: 

Do you have a valid drivers license?  Yes No

If NO  Please Explain: 

Drivers License Number: 

Drivers License State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY

How Is your driving record? 

Do you own a vehicle? Yes No

Year / Make / Model of vehicle: 

Vehicle License plate number:   Vehicle License plate state: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY

Referred by:   From :

Position Desired:  Auxiliary Field Team Search Management Dog Handler Other

Do you currently handle or work with a canine partner? Yes No

Why do you wish to become a  member of C.A.E.S.A.R.?

Have you ever applied to C.A.E.S.A.R. before? Yes No

If yes when?

Do you currently belong to any search and rescue organizations? Yes No

If yes, please name all organizations: 

Are you currently employed? Yes No

Employer telephone number: 

Employer Name: 

Employer Street: 

Employer City:    Employer State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY   Employer Zip Code:

May we contact your employer?  Yes No

If NO  Why? 

Have you ever been arrested or convicted of any crime? Yes No

If YES  Explain:

Are you under a physicians care for any medical condition or health problem? Yes No

If YES Explain:

Have you ever filed workmen's compensation claim? Yes No

If YES Explain:

Do you require ant special needs or assistance due to a handicap or deficit? Yes No

If YES Explain:

List any subjects of special study or research:

What foreign languages do you speak, read, or write fluently?:

List activities of interest:

Professional Education

High School: Diploma: Yes No Subjects Studied:

College: Degree: Subjects Studied:

Other: Degree: Subjects Studied:

Health or Search and Rescue Related Education

Course: Location:  Date:

Course: Location:  Date:

Course: Location:  Date:

References (not related to you)

Name:  Address: Phone Number: Years Acquainted:

Name:  Address: Phone Number: Years Acquainted:

Name:  Address: Phone Number: Years Acquainted:

Emergency Contacts

Name:  Address: Phone Number:

Name:  Address: Phone Number:

Name:  Address: Phone Number:

Agreement

        I certify that the answers given herein are true and complete to the best of my knowledge.  I authorize C.A.E.S.A.R. to make such investigations and inquiries of my personal, employment, or medical history and other related matters as may be necessary in arriving at a decision for membership.

        I hereby release Canine Aided Emergency Search And Rescue, Inc., its members, schools, employers, and persons from all liability regarding inquiries made in connection with this application.  In the event of acceptance, I understand that false or misleading information giving in this application or interview may result in immediate discharge.  I also understand that I am required to abide by all rules and regulations set fourth in the policies and procedures of Canine Aided Emergency Search And Rescue, Inc.

Date:   Electronic Signature: