FLAG CITY REACT
Membership Application Instructions
Please read first before filling in Application

Thank you for your interest in FLAG CITY REACT. We need the help of people like you to continue on the public service that we provide to our communities. The following instructions tell you what to do with the application after you are done filling it out.

You can either print out the application form and fill it in and mail it to us or you can fill it in on your computer, print it out and mail it or e-mail it to us.

Postal Mail instructions:
mail it to:
FLAG CITY REACT,
P.O. Box #237
Vanlue, Oh. 45890
Attention: Eric J. Brandeberry Jr.

E-mail and fax Instructions:
Fill in the form on your computer, Save the file and e-mail it to:
fcr6101@yahoo.com Or print Application and fax it to (419) 387-7219

NOTE: Please make Check or money order to: Flag City REACT for $42.00 ($32-cost of React International Dues & Insurance,$10 Team dues) when you turn in the application.

(Dues will be returned to you if application is not approved)

Again thank you for your interest in FLAG CITY REACT.

FLAG CITY REACT #6101             Approved/Disapproved __________
Membership Application   					          Date

Name____________________________________________________________
            		(Last)		(First)		(Middle)
Address__________________________________________________________
City____________________   State_________   Zip Code__________________
Home Phone_____________________   Work Phone_______________________
Wireless Phone___________________    Pager____________________________
Date of Birth________________    Social Security Number:_________________
Employment

Employer_________________________________________________________
Address__________________________________________________________
City____________________   State_________   Zip Code__________________
Occupation________________________________________________________
References

Name_____________________________Phone__________________________
Address__________________________________________________________
City____________________   State_________   Zip Code__________________

Name_____________________________Phone__________________________
Address__________________________________________________________
City____________________   State_________   Zip Code__________________
Criminal Background

1. Have you been convicted of a 1st or 2nd degree felony during your lifetime or a 3rd or 4th degree felony anywhere in the United States within the last 20 years? If so please list the state, date of conviction and crime committed.
         _____________________________________________________________________________

2. Have you been convicted of a misdemeanor anywhere in the United States in the last 7 years?
______________________________________________________________________________

Training
1. Are you certified as any of the following?
      ___ First Aid/ CPR	___EMT- Basic		___EMT - Intermediate
      ___ EMT – Paramedic  	___First Responder     	___ Firefighter
      ___ Search and Rescue	___Police Officer
      ___ Other  (please list)______________________________________
(Please enclose a photocopy of the stated certification. If you e-mail the application, have the certificate available at first team meeting you attend after submission of application)
2. Do you possess any of the following radio licenses?
___ GMRS               Callsign____________
___ Business Band   Callsign____________
___ Amateur Radio 
       Class___________________  Callsign_____________ 
___ Other (please list)_____________________________________
3. Please list the number and type (portable, mobile or base) of the following radio equipment.
	___ CB  _______________________________________________________
	___ GMRS (or capable radio) ______________________________________
	___ Amateur  ___________________________________________________
	___ Business Band _______________________________________________
	___ Other (please list) _____________________________________________
4. How do you intend to contribute to the team as a member of FLAG CITY REACT ?
________________________________________________________________________________________________________________________________________________________________

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I, the undersigned, if accepted for membership, do hereby agree to conform to the rules and regulations of FLAG CITY REACT under penalty of having my membership revoked. I further agree:
1.	I consent to a complete federal, state and local criminal background check, including fingerprinting.
2.	I have fully disclosed any crimes of which I have been convicted in the time periods specified.
3.	I will disclose to the Board of Trustees any criminal convictions within 3 days of said conviction while I am a member of FLAG CITY REACT.
4.	Upon receipt of written orders from officers and/or trustees of FLAG CITY REACT, I will discontinue use of the unit number assigned to me, return any equipment loaned to me by the team, and stop using any radio frequency (simplex or duplex) on which FLAG CITY REACT, has been licensed or granted access to, on which I am not legally licensed.
5.	I will be responsible for my conduct and indemnify and hold harmless FLAG CITY REACT, for death, injury and/or dismemberment while performing duties as a REACT member.
I understand and acknowledge the above agreement as a requirement for membership in FLAG CITY REACT.
Signature_________________________________ Date__________________
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FOR TEAM USE ONLY
Date Application Received _______________________________
Approved for:      Membership Committee _____________________ (date) _______________
                             Team ____________________________________ (date) _______________
Notified of:    Acceptance _________________________    Rejection _____________________
Dues Paid:     International   $_________ Date _________ Regular___ Family___ Junior___
                        Team Dues    $ ________
Membership Materials:   Ordered Date _______________   Presented _____________________
International Membership ID Number _______________________________________________