Gage County REACT #2983

PO BOX 94

BEATRICE NE, 68310


MEMBERSHIP APPLICATION

$5.00 fee (non-refundable) must accompany this application for police background check.

 

Name:

_____________________________________________________

Other Names:

(Maiden, Nickname)

_____________________________________________________

Mailing Address:

_____________________________________________________

Street Address:

_____________________________________________________

Date Of Birth:

_________________________ SSN:_______________________

Phone #’s

Home:____________________ Cell:______________________

Email Address:

_____________________________________________________

Employer:

_____________________________________________________

Location:

__________________________ Phone:____________________

Hours & Days of Employment:

_____________________________________________________

Radios Owned:

CB__FRS__GMRS__AMATEUR__Other:_______________________

FCC Call Sign(s):

_____________________________________________________

Vehicle License # and Description:

_____________________________________________________

Specialized Vehicles: (ATV, Air Boat, Plane, …)

_____________________________________________________

Insurance Carrier:

_______________________________________EXP___________

Drivers License #:

_______________________________________EXP___________

 

 

 

Any professional licenses? (CPA, Lawyer, Pilot, …)

__No

__Yes

Details*

Are you a medical professional? (DR., RN, LPN, EMT, …)

__No

__Yes

Details*

Are you a current or past member of law enforcement or fire fighter?

__No

__Yes

Details*

Have you ever been convicted of a felony?

__No

__Yes

Details*

Have you ever been arrested for DWI or DUI?

__No

__Yes

Details*

Have you ever been treated for alcohol or drug addiction?

__No

__Yes

Details*

Any reportable accidents in the last three years?

__No

__Yes

Details*

Has your drivers license ever been suspended or revoked?

__No

__Yes

Details*

*(use reverse as necessary)

Please tell us anything else you think we should know when considering your application:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

 

....................................................................
I certify that the above statements are true to the best of my knowledge and that any willful false statements may cause this application to be rejected. I understand that this application may be subject to review by law enforcement agencies who may check my driving and criminal records. I hereby consent to such inquiries.

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Signature of Applicant

 

------------------DO NOT WRITE BELOW THIS LINE----------------

APPROVED

APPROVED


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Beatrice Police Department


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Gage County Sheriff

 

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REACT Board of Directors