Full Name (Last, First MI):        Date of Birth: 

Address:      City:     

State:     Zip:   

Home Phone #:     Work Phone #:       Cell Phone #: 

E-Mail Address: 

Drivers License #:     State:     Expiration: 

Place of Birth:      Social Sec #: 

Place of Employment: 

Job Title: 

Job Description:

May we Call Your Work Number?  Yes ,  No

Emergency Contact:     

Relationship:  

Describe your skills and work experience, as well as you horsemanship skills:

HAVE YOU EVER BEEN ARRESTED OR HAD PROBLEMS WITH THE LAW WHICH WOULD EMBARRASS THE LOS ANGELES COUNTY SHERIFF'S DEPARTMENT?   YES ,  NO

IF YES, PLEASE EXPLAIN:

ANY FALSE STATEMENTS, EITHER VERBAL OR WRITTEN, MAY CAUSE THE APPLICANT TO BE REMOVED FROM THE ELIGIBLE LIST.

BY ENTERING MY INITIALS IN THE BOX BELOW AND SUBMITTING THIS FORM, I HEREBY AUTHORIZE THE LOS ANGELES COUNTY SHERIFF'S DEPARTMENT TO INITIATE A RECORDS CHECK PRIOR TO MY ACCEPTANCE AS A PALMDALE STATION VOLUNTEER.

INITIAL FORM: