Member Information Change & Operational Patriot Readiness Form
 
Name: Member No.:
Address:
City: State:             Zip Code:
Phone Numbers Home: Work: Cell: Fax:
  Others: Others:
Email Addresses Home: Work:
Maillist National Yes No   District Yes No Division YesNo  FlotillaYesNo

Emergency Contact Information

Name:  
Address:
City: State:             Zip Code:
Phone Numbers Home: Work: Cell: Fax:
  Others: Others:

Personal Training Qualifications

Qualification Have Want   Qualification Have Want
Coxswain   IT
Crew   TCT Facilitator
Pilot   LAMS IT
Air Crew   PATON Verifier
Observer   MEP First Responder
QE   Communication Watchstander
VE   Current Red Cross First Aid
CFVE   Current Red Cross CPR
TCT   ICS cert level: 100 200 300 400 Want

I have performed all currency maintenance for the above except:
I am willing to do CG or AUX Administrative Support missions: Yes No
I have these skill codes from the attached list:

I have had a security clearance within the last five years: Yes No
I am physically capable to do the duties which I am qualified and or registered to perform: Yes No
I have a current, laminated ID card, with photo: Yes No
I have the following additional CG qualifications/certifications:


Personal Availability

Anytime Weekends Weekdays Evenings Local Only Will Travel
Yes
No 		Yes
No 		Yes
No 		Yes
No 		Yes
No 		Yes
No

Surface Vessels Owned

Length Location Trailered In water Laid up Offered for use Under repair
Yes
No 		Yes
No 		Yes
No 		Yes
No *		 Yes
No
Yes
No 		Yes
No 		Yes
No 		Yes
No *		 Yes
No

Aircraft Owned

Type Location Offered for Use Is It Under Repair
Yes
No 		Yes
No

Radios Owned

Type Location Call Sign Fixed Mobile Offered for use Are They Under Repair
Yes
No 		Yes
No
Yes
No 		Yes
No


In filling out this form, you certify that you are physically/medically fit to
perform in the areas in which you have indicated above that you are or want to be qualified.  For security purposes please enter your date of birth (eg: mm/dd/yyyy) this will be used as your signature.

Date of Birth