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PLEASE PRINT  FORMCHECKBOX  New Application  FORMCHECKBOX  Revised Application (Complete only sections requiring change) Legal, Proper Name (last, first, middle initial): FORMTEXT      Preferred Name:  FORMTEXT      Social Security Number: FORMTEXT      Address (street mailing)  FORMTEXT      Date of Birth:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip Code:  FORMTEXT      Occupation:  FORMTEXT      Email Address:  FORMTEXT      Home Phone: FORMTEXT      Work Phone incl. area code:  FORMTEXT      Cell Phone incl. area code:  FORMTEXT      Red Cross Personnel Category: FORMCHECKBOX  Volunteer  FORMCHECKBOX  Chapter Employee  FORMCHECKBOX  National EmployeeIf Red Cross Employee: FORMCHECKBOX  Exempt  FORMCHECKBOX  Non-Exempt (attach a completed form 6494A) Passport Expiration Date: FORMTEXT      Country of Issuance: FORMTEXT      Driver s License Number: FORMTEXT      State:  FORMTEXT    Driver s License Classification:  FORMTEXT      Other License(s)/Certificate(s) (REQUIRED): Type:License/Certification Number:State:Expiration Date: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Language(s)  list proficient languages other than English and proficiency rating (R=Read Only, S=Speak Only, F=Fluent)  FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT    RED CROSS UNIT/CHAPTER AFFILIATION - Complete with information about your unit that will be used to recruit you for disaster operations.Unit/Chapter Name:  FORMTEXT      Chapter Code:  FORMTEXT      Service Area (Unit): FORMDROPDOWN Group Affiliation  FORMCHECKBOX  American Southern Baptist Mission Board  FORMCHECKBOX  Church of Brethren  FORMCHECKBOX  Labor Union Affiliation  FORMCHECKBOX  USPHS  FORMCHECKBOX  NCCC  FORMCHECKBOX  NPRC  FORMCHECKBOX  AmeriCorps  FORMCHECKBOX  Learn and Serve  FORMCHECKBOX  Senior Corps  FORMCHECKBOX  Current Group Affiliation  FORMCHECKBOX  Past Group Affiliation Year  FORMTEXT       DISASTER RELIEF OPERATION HISTORY Complete with information regarding any disaster assignments on which you have served and which will substantiate your disaster history, particularly for your Group and Activity preferences. Refer to your unit Disaster Services Human Resources System representative to clarify DR numbers, operation names, and positions in which you served. Write LOCAL if no DR# was assigned.DISASTER OPERATION GROUP AND ACTIVITY PREFERENCE Discuss with your units Disaster Services Human Resources System representative the Disaster Operation activities which you meet the competency criteria. Complete in order of preference. 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Introduction to Disaster Services, CPR and a First Aid certificate are required for all DSHR System members. Indicate MO/DA/YR in which a course was most recently completed.LIFE EXPERIENCE INFORMATION (Note any skills, knowledge, non-Red Cross training, management, supervisor and life experiences that assist in meeting competency criteria as listed in the Competency Criteria. Add additional pages as needed.COURSE NAMEMonth/Day/Year FORMTEXT      Introduction to Disaster Services FORMTEXT       FORMTEXT      First Aid FORMTEXT       FORMTEXT      CPR FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       TO BE NOTIFIED IN CASE OF EMERGENCY (REQUIRED)Name:  FORMTEXT      Relationship:  FORMTEXT      Address (street/mailing):  FORMTEXT      Home Phone incl. area code:  FORMTEXT      City:  FORMTEXT      Work Phone incl. area code:  FORMTEXT      State:  FORMTEXT    Zip Code:  FORMTEXT      Cell Phone incl. area code:  FORMTEXT       APPLICATIONS WITHOUT PROPER SIGNATURES CANNOT BE ACCEPTED The Disaster Services Human Resources (DSHR) System has my permission to verify this information. I verify that I have not been convicted of a felony, or been convicted of a misdemeanor that resulted in imprisonment. 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