UNITED STATES WATER PATROL
Information form

1. Name. _____________________________
2. Address__________________________________________
3. Age._______ Birth Date.______________
Phone1 _______________ Phone 2_______________
4. Boat. Y N    type ___________ length______  year _____ Boating Exp. _______ Fresh _____ Salt ______ River _____ Lake______ Other_____________
5.  Other Exp. Are you or have you ever been.
a. Policemen Y N    b. Fireman Y N    c.  EMT Y N 
d. other __________________
6 Can you do any of the following?
a. Operate a boat Y N   b Dive Y N    c. boat repair Y N d  Drive truck Y N    e. Fly Y N
f. Operate a Gen. Y N  g. Use a 2 way radio Y N   h Sky Dive Y N  I Swim  Y N
j read maps Y N/ charts Y N / GPS  Y N / compass Y N   k  Fire Arm Y N
7. In the event of an EM can you travel Y N for how long at a time_________________
8. Have you ever been in the Service?  Y N
a. Branch_____________ fr  _____ to _______ retired Y N
MOS_____________________________________
9. Do you have any collage experience? Y N  Major______________________________
Would you be interested in a leadership position?  Y N
Would you be interested in starting a station if not one in your area?  Y N
Would you be interested in a National position Y N
Would you be interested in being an adviser Y N on______________________________
Would you be interested in being a contact point for information for the USWP  Y N

10. Other information ________________________________________________________________________

Do not write below this line for office use +++++++++++++++++++++++++++++++++++++++++++++++
Start Date_________ Region____________ Rank_____________
Recommendations____________________________________________________________________________________________________________________
Assingment___________________________________________________________________________________________________________________________


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