# DISASTER SERVICE WORKER REGISTRATION Charter      

+-------------+--------------------------------------------------------+
| LOCAL AND   |                                                        |
| STATE       |                                                        |
| INFORMATION |                                                        |
|             |                                                        |
| Loyalty     |                                                        |
| Oath under  |                                                        |
| Code of     |                                                        |
| Civil       |                                                        |
| Procedure   |                                                        |
| \# 2015.5 & |                                                        |
| Title 19,   |                                                        |
| Div.2,      |                                                        |
| Chap.2,     |                                                        |
| Sub-Chap.3, |                                                        |
| #2573.1     |                                                        |
+-------------+--------------------------------------------------------+
| ATTACH      | ##                                                     |
|             |                                                        |
| PHOTOGRAPH  | ## This block to                                       |
|             | be completed ONLY by government agency or jurisdiction |
| HERE        |                                                        |
|             | CLASSIFICATION: SPECIALTY:                             |
| (Optional)  |                                                        |
|             | AGENCY OR JURISDICTION:                                |
|             |                                                        |
|             | REGISTRATION DATE: RENEWAL DATES:                      |
|             |                                                        |
|             | EXPIRATION DATE: \* DSW CARD ISSUED: NO YES \#         |
|             |                                                        |
|             | PROCESSED BY: DATE: TO CENTRAL FILES:                  |
+-------------+--------------------------------------------------------+

TYPE OR PRINT IN INK (HIGHLIGHTED AREA REQUIRED BY PROGRAM REGULATIONS)

<table>
<colgroup>
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<col style="width: 17%" />
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<tbody>
<tr class="odd">
<td colspan="2"><p>NAME LAST</p>
<p>     </p></td>
<td colspan="4"><p>FIRST</p>
<p>     </p></td>
<td colspan="3"><p>MI</p>
<p>   </p></td>
<td colspan="3"><p>SSN:</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="4"><p>ADDRESS:</p>
<p>     </p></td>
<td colspan="5"><p>CITY:</p>
<p>     </p></td>
<td><p>STATE:</p>
<p>  </p></td>
<td colspan="2"><p>ZIP:</p>
<p>     -    </p></td>
</tr>
<tr class="odd">
<td colspan="4"><p>COUNTY:</p>
<p>     </p></td>
<td colspan="5"><p>HOME PHONE:</p>
<p>   -   -    </p></td>
<td colspan="3"><p>WORK PHONE:</p>
<p>   -   -     Ext -     </p></td>
</tr>
<tr class="even">
<td colspan="4"><p>PAGER:</p>
<p>   -   -    </p></td>
<td colspan="5"><p>E-MAIL:</p>
<p>     </p></td>
<td colspan="3"><p>DATE OF BIRTH: (Optional)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="4"><p>DRIVER LICENSE NUMBER: (if applicable)</p>
<p>     </p></td>
<td colspan="3"><p>DRIVER LICENSE CLASSIFICATION:</p>
<p>     </p>
<p>OTHER DRIVING PRIVILEGES:</p></td>
<td colspan="2"><p>A B C</p>
<p> </p></td>
<td colspan="3"><p>LICENSE EXPIRATION DATE:</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="4"><p>PROFESSIONAL LICENSE: (if applicable)</p>
<p>     </p></td>
<td colspan="5"><p>FCC LICENSE: (if applicable)</p>
<p>     </p></td>
<td colspan="3"><p>LICENSE EXPIRATION DATE:</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="9"><p>IN CASE OF EMERGENCY, CONTACT:</p>
<p>     </p></td>
<td colspan="3"><p>EMERGENCY PHONE:</p>
<p>   -   -    </p></td>
</tr>
<tr class="even">
<td><p>PHYSICAL</p>
<p>IDENTIFICATION</p></td>
<td colspan="2"><p>HAIR:</p>
<p>     </p></td>
<td colspan="2"><p>EYES:</p>
<p>     </p></td>
<td colspan="3"><p>HEIGHT:</p>
<p> ‘   “</p></td>
<td colspan="3"><p>WEIGHT: (optional)</p>
<p>   </p></td>
<td><p>BLOOD TYPE: (optional)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="12"><p>COMMENTS:</p>
<p>     </p></td>
</tr>
</tbody>
</table>

Government Code #3108-3109:

Every person who, while taking and subscribing to the oath or
affirmation required by this chapter states as true any material matter
which he knows

to be false, is guilty of perjury, and is punishable by imprisonment in
the state prison not less than one nor more than 14 years. Every person
having

taken and subscribed to the oath or affirmation required by this
chapter, who, while in the employ of, or service with, the state or any
county, city,

city and county, state agency, public district, or disaster council or
emergency organization advocates or becomes a member of any party or

organization, political or otherwise, that advocates the overthrow of
the government of the United States by force or violence or other
unlawful means, is guilty of a felony and is punishable by imprisonment
in the state prison.

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+-----+------------------------------+--------------------------------+
|     |                              |                                |
+-----+------------------------------+--------------------------------+
|     | I,                           | , do solemnly swear (or        |
|     |                              | affirm) that I will support    |
|     | PRINT NAME                   | and defend the                 |
+-----+------------------------------+--------------------------------+
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+-----+------------------------------+--------------------------------+
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+-----+------------------------------+--------------------------------+

\*Registration for the active DSW volunteer is effective for the period
the person remains a member with that organization; for a volunteer
registering for an

intermittent or a single event, the expiration date is set at the
discretion of the accredited Disaster Council but not to exceed one
year. (Govt Code #3102)

OES 2000 Rev. 9/00 Entered into OES data base: Date: