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Reading Volunteer Crime Watch Program Information

APPLICATION FOR MEMBERSHIP

Reading Volunteer Crime Watch, Inc. I.D. Card No.

PO Box 12984

Reading, PA 19612-2984 Region

I, the undersigned, do hereby request that I be considered for membership in Reading Volunteer Crime Watch, Inc.

1. Name: Last First M.I.

2. Address Reading, PA

Zip Code

3. Telephone Date of Birth

4. Employer Phone

5. Address

6. Social Security Number PA Driver's Lic. No.

7. Vehicle Information:

#1

Color Year Make Model License No.

#2

Color Year Make Model License No.

In order to determine my acceptability for membership, I hereby authorize Reading Volunteer Crime Watch, Inc. through the Reading Police Department, to examine any and all motor vehicle records to ascertain what charges, if any, have been brought against me.

In the event I am selected to participate in the Crime Watch Program, I hereby agree as follows:

1. I hereby release Reading Volunteer Crime Watch, Inc. and the City of Reading, and all of their officials, employees and other Crime Watch association members from any and all liability with regard topersonal injury or property damage that I may sustain while participating in crime Watch activities.

2. I further agree to indemnify and hold harmless Reading Volunteer Crime Watch, Inc. and the City of Reading and all their officials, employees and other Crime Watch members from any and all liability to include court costs and legal fees from any action brought against any of them as a result of my participation in the

Crime Watch program.

3. I understand that all expenses incurred by me are voluntary contributions, and that Reading Volunteer Crime Watch, Inc. or the City of Reading, make no promises of reimbursement.

Applicant's Signature & Date

Record Check I.D. Card Made I.D. Card Mailed

Rev. 8.01 app