City of Perham Minnesota

RESERVE OFFICER APPLICATION

Date: Social Security Number: Telephone Number:

Name: last first middle

Present Address:

General Information

Single Married Widowed Divorced Separated

Own Home Rent Board Live with Parents Live with Relatives

Date of Birth: Number of Children: Ages of Children: Other Dependents:

If related to anyone in this organization, give name:

Have you received a notice to report for duty in the Armed Services: Yes No

Are you a veteran? Yes No Honorable Discharge? Yes No

Education

Vehicle Operation

Driver's License Number: State: Expiration Date:

Do you own an automobile? Yes No If yes, make and year?

Do you have auto insurance? Yes No Has it ever been cancelled? Yes No

Have you been involved in ANY vehicle accidents within the past 3 years? Yes No

How many traffic tickets for MOVING violations within the past 3 years?

Has your driver's license EVER been suspended or revoked? Yes No

By clicking submit, I authorize investigation of all statements contained in this application.
By clicking submit, I understand that misrepresentation or omission of facts called for is cause for dismissal and that my membership is substantially dependent on truthful answers to the foregoing inquiries.


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