Coast Guard Auxiliary Flotilla 081-01-04

Profile and Summary of Prospective (New) Member

Today’s date:  ________ 

For additional space please use the back of this form.

NEW MEMBER’S PERSONAL DATA:

Last name: __________ First name:  __________ Nick name:  ______

Age:  (__) ­­­­   Birth month/year:  __/____.

HOME ADDRESS: Street (only):   ___________ City : ___________ State : __

Home Phone: (___) ___-____ Cell Phone:  (___) ___-____

Work Phone:     (___) ___-____

Home E-Mail Address:  ______________@_________.____                                               

Work: E-Mail Address:  ______________@_________.____

PRIOR MILITARY or UNIFORMED INFORMATION:

Have you had Military or other Uniformed Experience?

Yes (___) or No (___)

What Service:

(___) USCG                 (___) ARMY                 (___) ARMY NATIONAL GUARD

(___) USCG Reserves (___) ARMY Reserves (___) MARINES

(___) NAVY                  (___) NAVY Reserves (___) MARINES Reserves

(___) Police                  (___) Fire   Department  

(___)Any other not listed: _______________________                

What did you do in the military or uniformed service?  _____________________
________________________________________________________________

Total time in Service: ___   Type of Discharge: ________ Highest Rank held:  ___

For additional space please use the back of this form.

OCCUPATION OR CURRENT STATUS:

What is your present occupation?  ____________________________________

________________________________________________________________

Explain what you do at your present job:  _______________________________                                                                               

What other jobs have you had?  ______________________________________

What experience, in your past do you think will help the Coast Guard Auxiliary? 

________________________________________________________________

Have you ever been in the Coast Guard Auxiliary?           Yes (__) No (__)  

All the information provided or asked in this interview is strictly used to assist in expediting or developing reason if or if not why member can not be accepted in the Auxiliary – No portion or any part of the material will be disseminated so as to harm the person seeking to join the volunteer organization of The United States Coast Guard Auxiliary. I am interested in finding out more about the Coast Guard Auxiliary.  Please contact me when time permits?  

Please Sign and mail to the address below:     Sign:   ___________________________