Old Mill Park Homeowners Association, Inc.

Community Emergency Response Team Application

APPLICATION

Interested in volunteering to assist your neighborhood during a disaster?
We are currently accepting volunteer applications. Meetings and classes to begin shortly. Please print and complete application and mail to:


Old Mill Community
Emergency Response Team
ATTEN: RECRUITMENT
5620 Dollar Hide South Drive
Indianapolis, IN. 46221

please print and complete

Emergency Response Team Member

Name:
_______________________________________

Address:
_______________________________________

_______________________________________

Home Phone:
_______________________________________
Work Phone:
_______________________________________
Cell Phone:
_______________________________________
Pager:
_______________________________________

Date of Birth:
_______________________________________
Drivers License #:
_______________________________________
State Issued:
_______________________________________

List any criminal convictions in the past ten (10) years:
_______________________________________

_______________________________________

_______________________________________

Vehicle 1)

Make:
_______________________________________

Model:
_______________________________________

License Plate:
_______________________________________

Vehicle 2)

Make:
_______________________________________

Model:
_______________________________________

License Plate:
_______________________________________


I hereby authorize the officers of the Old Mill Park Community Emergency Response Team to conduct any necessary investigation, or interview with any law enforcement agency, or sheriff's office, for the sole purpose of approving my membership into the Old Mill Park Community Emergency Response Team. I hereby declare all information included in this application to be true to the best of my ability.


Prospective Members Signature:



_______________________________________

Prospective Members Name (PRINTED)



_______________________________________