First Name: ________________________

Middle Initial: ______

Last Name:_________________________

Date of Birth:________/______/_________

Current Age: _______

Grade (If applicable):______ School:___________________________________

Home Address: ___________________________________________________________

City:____________________________________ Zip Code:_____________________

Home Phone Number: ______________________ Cell Phone: ____________________

E-mail Address:__________________________________________________________

** Regular Access to the Internet? ٱ Yes ٱ No

Occupation (E.G. Student, Wal-Mart):_________________________________________

Special Training (E.G. Grand Rapids Fire, W.C. Rescue 3):________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

C:\WINDOWS\Profiles\Explorer Post 130\My Documents\Membership Information Sheet.doc

John Baker Page 1 05/31/04