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2. EXPLORER POST 343 MEMBERSHIP APPLICATION

   Print all information legibly in ink. Answer all questions accurately and completely. Any false statement will disqualify you from this program

4. Name
6. Phone Number
7. Email Address
9. Address
11. City
12. State
13. Zip Code
15. Date of Birth
16. Age
17. Place of Birth (City/State)
19. Social Security Number
20. Driver's License Number
22. Name of Parent/Guardian
24. Parent/Guardian Home Phone
25. Parent/Guardian Cell Phone
27. Parent/Guardian Address
29. Last School Attended
30. Grade
31. GPA
33. Give names of clubs, societies, and other similar organizations to which you belong (other than religious or ethnics).
35. Have you ever had contact with any police agency as a juvenile offender? If yes, give circumstances, date, location and crime.
37. Have you ever been arrested? If yes, give circumstances, date, location and crime.
39. Personal References:
    Give 3 personal references (can include employers and teachers) whom you have known for at least 2 years.
41. 1. Name
42. Address
44. Phone
45. Years Acquainted
46. Relationship
48. 2. Name
49. Address
51. Phone
52. Years Acquainted
53. Relationship
55. 3. Name
56. Address
58. Phone
59. Years Acquainted
60. Relationship
62. List names of any relatives now employed by the County of Lenawee and relationship.
64. Health Record:
66. Do you have a physical disability that would prevent you from preforming the essential duties of an Explorer? If yes, please list disability
68. In case of emergency notify:
    Name, Relation, Address, Telephone Number
70. NOTICE:
    Any false statement, evasion, or deception in the answers to the above questions will be considered sufficient grounds for rejection or dismissal from program.
72. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
74. Electronic Signature
    Signature of Applicant as Usually Written
75. Date
77. Applications valid for one year from date submitted.
Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

* indicates a required field