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Explorer's Membership Application


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

  2. Personal References:
    Give 3 personal references (can include employers and teachers) whom you have known for at least 2 years.
  3. Health Record:
  4. Name, Relation, Address, Telephone Number
  5. 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.
  6. 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.
  7. Signature of Applicant as Usually Written
  8. Applications valid for one year from date submitted.
  9. Leave This Blank:

  10. This field is not part of the form submission.