Application – Flatbush Shomrim Safety Patrol

Application Form

Please fill out the application form, and we will respond to you at our earliest opportunity.

Name

Home Phone Number

Work Phone Number

Cell Phone Number

Address

Date of Birth

Marital Status

Drivers License Number

State of License

Drivers License Photo

Where do you Daven during the week?

Where do you Daven on Shabbos?

Are you or have you ever been a member of any organizations?

Summer Months

Employers name, address, and phone number

Vehicle Make/Model

Plate #

State Registered

Ref #1 Name

Ref #1 Address

Ref #1 Phone Number

Ref #2 Name

Ref #2 Address

Ref #2 Phone Number

Which days are you available

Which hours are you available

I will patrol on my assigned night(s)

I will adhere to the rules and regulations of the FSSP

I understand and agree that the radio and/or any equipment assigned to me is the property of the FSSP and must be surrendered upon request.

I affirm that I understand the regulations of the FSSP and that the above information and statements are true and accurate

Applicant's Name

Date

Checking this box shall function as an electronic signature