SENIOR

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<tbody>
<tr class="odd">
<td colspan="5" rowspan="2"><p><strong>APPLICATION FOR SENIOR
MEMBERSHIP<br />
IN CIVIL AIR PATROL</strong></p>
<p><em><strong>(Type or print. Chaplains must use CAPF
35.)</strong></em></p></td>
<td colspan="9">CHARTER NUMBER</td>
<td colspan="4">SOCIAL SECURITY NUMBER</td>
</tr>
<tr class="even">
<td colspan="9">     </td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="4"><p>LAST NAME - FIRST NAME - MIDDLE INITIAL</p>
<p>             </p></td>
<td colspan="3"><p> MALE</p>
<p> FEMALE</p></td>
<td colspan="2"><p>HEIGHT</p>
<p>   </p></td>
<td colspan="2"><p>WEIGHT</p>
<p>   </p></td>
<td colspan="6"><p>BLOOD TYPE</p></td>
<td><p>DATE OF BIRTH</p>
<p>DAY MONTH YEAR</p>
<p>     </p></td>
</tr>
<tr class="even">
<td><p>MAILING ADDRESS (Number and Street)</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td><p>APT</p>
<p>    </p></td>
<td colspan="10"><p>CITY      </p>
<p>STATE   </p></td>
<td colspan="5"><p>ZIP CODE</p>
<p>     </p></td>
<td><p>HOME PHONE</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="18"><p>Email address (This address may be used to contact
you concerning CAP events, special interest items and other membership
information)</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="16" rowspan="2"><p>NEXT OF KIN (Name and address)      </p>
<p>     </p></td>
<td colspan="2">RELATIONSHIP:</td>
</tr>
<tr class="odd">
<td colspan="2">PHONE: (   )      </td>
</tr>
<tr class="even">
<td colspan="18"><p>MEMBER MOST RESPONSIBLE FOR YOUR JOINING CAP
(OPTIONAL : For recruiting purposes<em>)</em></p>
<p>NAME       CAPSN       CHARTER #      </p></td>
</tr>
<tr class="odd">
<td colspan="6">EMPLOYED BY</td>
<td colspan="7">POSITION HELD</td>
<td colspan="5" rowspan="2"><p>WORK PHONE: (   )      </p>
<p>MAY WE CALL YOU AT WORK? </p></td>
</tr>
<tr class="even">
<td colspan="6"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="7">     </td>
</tr>
<tr class="odd">
<td colspan="8"><p>EDUCATION (ENTER NUMBER INDICATING YEAR COMPLETED: 9
- 20 or OTHER)</p>
<blockquote>
<p>GRADE COMPLETED </p>
</blockquote></td>
<td colspan="5"><p>DEGREE RECEIVED</p>
<p>     </p></td>
<td colspan="5"><p>PROFESSION / TEACHING CERTIFICATE</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="18"><blockquote>
<p><strong>To help us better serve our members, please tell us how you
heard about Civil Air Patrol (check all that apply):</strong></p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2"><blockquote>
<p> Air Show</p>
<p> NASCAR Race Program</p>
<p> CAP Member</p>
<p> Friend</p>
<p> Magazine</p>
<p> Family Member</p>
</blockquote></td>
<td colspan="14"><blockquote>
<p> CAP Exhibit</p>
<p> School</p>
<p> Radio</p>
<p> Television</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="6"><blockquote>
<p> Other (please name):</p>
</blockquote></td>
<td colspan="8">     </td>
</tr>
<tr class="odd">
<td colspan="18"><p><strong><em>VOLUNTARY STATISTICAL INFORMATION</em>
(FOR DEMOGRAPHIC RESEARCH ONLY -- NOT REQUIRED FOR
MEMBERSHIP)</strong></p>
<p><strong>A:</strong> IDENTIFICATION: WHITE BLACK (NOT OF HISPANIC
ORIGIN) HISPANIC ASIAN/PACIFIC ISLANDER</p>
<p> AMERICAN INDIAN/ALASKAN NATIVE</p>
<p><strong>B:</strong> INCOME $0-$25,000 $25,001-$50,000 $50,001-$75,000
$75,001-$100,000 OVER $100,000</p></td>
</tr>
<tr class="even">
<td colspan="18"><p><em><strong>BACKGROUND INFORMATION</strong></em></p>
<p><strong>A. CITIZENSHIP</strong></p>
<blockquote>
<p>1. Are you a citizen of the United States? 2. Are you an alien
admitted for permanent residence? _____<br />
(Must possess current alien registration receipt card (Form I-151 or
I-551).</p>
</blockquote>
<p><strong>B. ARRESTS/CHARGES</strong> (WRITE “NONE” IF APPROPRIATE)
<u>    <br />
</u>List on a separate sheet, all arrests or charges regardless of age
or whether the record in your case has been sealed, expunged, or
otherwise stricken from the court records. You must also include all
military courts-martial or non-judicial punishment (Article 15, UCMJ or
Captain’s Mast). Failure to provide all required information may result
in your membership application being denied. (<strong>Note:</strong> You
may exclude minor traffic violations unless drugs, alcohol or injury
were involved.)</p>
<p><strong>C. prior military service</strong> (WRITE “NONE” IF
APPROPRIATE) <u>     </u> <u>     </u> <u>     </u> <u>     </u></p>
<blockquote>
<p>Branch of Service Grade Discharge Date Discharge Type</p>
</blockquote>
<p><strong>D. PRIOR CAP MEMBERSHIP</strong> (WRITE “NONE” IF
APPROPRIATE)<br />
<u>from</u> <u>to</u> CADET HIGHEST CADET AWARD EARNED <u>     <br />
</u> <u>                 </u> SENIOR HIGHEST GRADE EARNED
<u>     </u></p>
<p>Old Charter #</p>
<blockquote>
<p><strong>Was your membership nonrenewed or terminated for
cause?</strong> <strong>If yes, provide details on a separate sheet of
paper.</strong></p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="18"><p><em><strong>In applying for membership in Civil Air
Patrol, I hereby execute the oath on the reverse side and understand and
agree as follows:</strong></em></p>
<p><strong>(a)</strong> To permit CAP to use my Social Security Number
in my membership records as an identification number and to obtain
background<br />
information from any person, corporation, or government agency (local,
state, or federal) to be used to determine membership eligibility;<br />
<strong>(b)</strong> that if my membership eligibility is questioned, I
will be notified and provided the reasons; <strong>(c)</strong> that
prior to a final decision on my<br />
eligibility, I will have an opportunity to submit documentary evidence
on my behalf; and <strong>(d)</strong> that CAP membership is a
privilege and not a<br />
right and CAP’s decision on my membership eligibility is final.</p></td>
</tr>
<tr class="even">
<td colspan="15">APPLICANT SIGNATURE <strong>(Must be accompanied by FBI
fingerprint card, FD-258)</strong></td>
<td colspan="3"><p>DATE</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="18"><strong>To be completed by commander or designated
representative:</strong> I certify that the applicant is accepted as a
member of Civil Air Patrol subject to approval by higher headquarters
with National Headquarters as the final approving authority. Membership
becomes effective when this application is processed by National
Headquarters and the individual’s name appears on the National
Headquarters database.</td>
</tr>
<tr class="even">
<td colspan="18"><p>CHARTER, UNIT NAME, AND ADDRESS</p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="3"><p>TYPE OR PRINT FULL NAME</p>
<p>     </p></td>
<td colspan="12">SIGNATURE</td>
<td colspan="3"><p>DATE</p>
<p>     </p></td>
</tr>
</tbody>
</table>

CAP FORM 12, MAR 03 FRONT previous editions WILL NOT BE USED AFTER 30
JUN 03 OPR/ROUTING: DP

+-----------------------------------------------------------------------+
| **WHAT CAP ACTIVITIES ARE YOU MOST INTERESTED IN?**                   |
|                                                                       |
| **AEROSPACE EDUCATION PROGRAM** **CADET PROGRAM** **EMERGENCY         |
| SERVICES**                                                            |
|                                                                       |
| > AEROSPACE EDUCATION OFFICER DRILL AND CEREMONIES CHECK PILOT\       |
| > AEROSPACE EDUCATION INSTRUCTOR DRIVER COUNTERDRUG PILOT\            |
| > CADET AEROSPACE OPPORTUNITIES ENCAMPMENT STAFF DISASTER RELIEF\     |
| > COUNSELOR FLIGHT ENCAMPMENT STAFF INSTRUCTOR PILOT\                 |
| > SPEAKER INSTRUCTOR SEARCH AND RESCUE\                               |
| > LEADERSHIP POSITION GROUND TEAM\                                    |
| > ORIENTATION PILOT PILOT\                                            |
| > SPECIAL ACTIVITIES STAFF OBSERVER/SCANNER\                          |
| > RADIO COMMUNICATIONS                                                |
|                                                                       |
| **PLEASE LIST ANY OTHER SKILLS OR INTERESTS YOU HAVE WHICH MIGHT BE   |
| HELPFUL TO YOUR CAP UNIT.**                                           |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+
| **OATH OF APPLICATION**                                               |
|                                                                       |
| (READ CAREFULLY BEFORE SIGNING FRONT OF APPLICATION!)                 |
|                                                                       |
| **I do solemnly swear (or affirm) that:**                             |
|                                                                       |
| I understand membership in Civil Air Patrol is a privilege, not a     |
| right, and that membership is on a year-to-year basis subject to      |
| annual renewal by CAP. I further understand failure to meet           |
| membership eligibility criteria will result in automatic termination  |
| at any time.                                                          |
|                                                                       |
| I understand only Civil Air Patrol corporate officers are authorized  |
| to obligate funds, equipment, or services.                            |
|                                                                       |
| I understand Civil Air Patrol is not liable for loss or damage to my  |
| personal property when operated for or by Civil Air Patrol.           |
|                                                                       |
| I voluntarily subscribe to the objectives and purposes of Civil Air   |
| Patrol and agree to be guided by the CAP constitution and Bylaws and  |
| comply with CAP rules and regulations as from time to time may be     |
| amended or promulgated.                                               |
|                                                                       |
| I agree to abide by the decisions of those in authority of Civil Air  |
| Patrol                                                                |
|                                                                       |
| I certify that all the information on this application is presently   |
| correct and any false statement may be cause to deny membership. I    |
| understand I am obligated to notify Civil Air Patrol if there are any |
| changes to the background information on the front of this form and   |
| further understand that failure to report such changes may be grounds |
| for membership termination.                                           |
|                                                                       |
| I understand that this Oath of Application is a part of this          |
| application for senior membership in Civil Air Patrol and that my     |
| signature on the form constitutes evidence of that understanding.     |
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CAP FORM 12 REVERSE