Application For Membership

Date (required)

Personal Information

Name (required)

Date Of Birth (required)

Address (required)

Phone (required)

Laurel County resident?

Yes

Are you employed?

Yes

	0	1-5	5+	N/A
Illnesses requiring hospitalization over last 3 years: (required)	0	1-5	5+	N/A
Days lost due to illness over last year: (required)	0	1-5	5+	N/A

Driver's License Number

Have you had any driving violations in the last 5 years?

Yes

A background check may be completed if considered for a position.

Have you ever been convicted of a misdemeanor or felony?

Yes

Have you served in the Armed Forces of the United States?

Yes

Specialty School / Certifications

I agree to have a background check completed on me.

Yes

Signature