Shmira Application
This is the general application for Los Angeles Shmira Civilian Safety Patrol. Please answer all questions truthfully.
Name (First M. Last) *
Your answer
Date of Birth *
Your answer
Drivers License or ID Number *
Your answer
Vehicle Insurance provider *
Your answer
Insurance Policy Number *
Your answer
Email Address *
Your answer
Street Address *
Your answer
Home Number *
Your answer
Cell Number *
Your answer
Occupation *
Your answer
Name of Workplace or School *
Your answer
How did you hear about LA Shmira? *
Your answer
Why do you want to be a member of Shmira? *
Your answer
What Programs are you interested in? *
Required
Do you have any specialized skills, certifications, hobbies or interests? *
Your answer
What is your Highest level of education? *
Do you Speak a foreign language (if so, which?) *
Your answer
Have you ever been a member of Shmira or Shomrim in L.A. or elsewhere? *
If yes, explain when, where and reasons for leaving
Your answer
Answering yes to the following questions may not necessarily disqualify you from membership.
have you ever been convicted of a criminal offence other then a minor traffic infraction? *
Are you applying for the purpose of news or intelligence, investigative or research work? *
Do you have any medical conditions that could possibly interfere with your ability to maintain mental alertness, or participate in strenuous physical exercises? *
Please list 3 references (No immediate family members)
Please list one reference in each of the following 3 fields. Please list the full name (First, middle initial and last name, a phone number and email address for each reference as well as what your relationship to the reference is.
First Reference *
Your answer
Second Reference *
Your answer
Third Reference *
Your answer
I authorize Los Angeles Shmira to contact the references listed herein. I authorize the references listed herein to provide Los Angeles Shmira with information regarding my application and character. I also authorize Los Angeles Shmira to conduct a criminal background investigation for the purpose of verifying eligibility for membership. *
I understand that if accepted, I will be required to abide by all rules and regulations of the LOS ANGELES SHMIRA CIVILIAN PATROL. *
Required
I understand that if I participate in patrol activities, I will be required to undergo progressively strenuous and intense training exercises. I will also be required to patrol in hazardous areas with high levels of criminal activity and assist those in need when safe to do so. I have read the LA Shmira Code of Conduct and certify that I will follow all Shmira Rules and Regulations, if approved. *
Waiver And Consent Form:
To be filled out by applicants age 21 and over.
I hereby release the Los Angeles Shmira Civilian Patrol from all responsibility for any and all injuries I might incur while in training, on patrol, or in any other Los Angeles Shmira Civilian Patrol group function. I realize and accept that I am fully responsible for my own medical expenses.I have read, understood the above agreement. *
I certify that the information provided is true and complete to the best of my knowledge and understand that knowingly providing false or misleading information will result in disqualification or dismissal. *
Date of Application *
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