Last Name, First Name, M.I.:

Street Address:
City:State (2 letter):
Zip:

Home Phone:Work Phone:Cell Phone:
Pager:

E-Mail:

OccupationOrganization:Station Number:Shift:

TRAINING
Please list the date of your Certification (Must be a 40-hour State Class Cert.)

RS-1:RS-2:Swift Water RescueConfined Space Rescue
Trench Rescue

OTHER RELATED TRAINING

Annual Membership Dues
Regular - $20.00 Associate - $20.00 (Non KCFD Employee) Organizational - $50.00

Please Make Checks Payable to: KERN HEAVY RESCUE, Inc.

I give $:per year through United Way (must re-designate KHR each year)

TYPE OF MEMBERSHIP
Continuing Member

New Member

REFERRAL INFORMATION
Not Referred

Referred

Referred By:

Thank you For your application. The Treasurer will be contacting you!