Ocean City Beach Patrol - Personal Data Form
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1OCEAN CITY BEACH PATROL
Personal Data Form
Please provide all requested information with accuracy!
(PRINT)
Name: ___________________________, __________________________, ____________________________
(First)
(Middle)
(Last)
Name you wish to be addressed by: _______________ Social Security Number: _______-________-________
Date of Birth: ________/________/________
Current Age: _________
Drivers Soundex Number: ___________________________________________ State: _________________
Cell Phone
_______________________________ Cell Provider (for texting) _________________________
E-Mail Address
___________________________________________________
(Print it exactly as it must be typed)
ADDRESS INFORMATION
(if any of these addresses change it is your responsibility to notify the Beach Patrol immediately)
Permanent Address: ________________________________________ Phone: (_______) ________-________
(W-2's Sent Here)
Town: _______________________________ State: __________ Zip Code: ______________
Winter Address: ___________________________________________ Phone: (_______) ________-________
(Correspondence)
Town: _______________________________ State: __________ Zip Code: ______________
Summer Address: __________________________________________ Phone: (_______) ________-________
(Ocean City Vicinity)
Town: _______________________________ State: __________ Zip Code: ______________
If you are living in Ocean City during the summer, what is the closest beach you could
respond to in the event of an off duty emergency?
Street
Who is to be contacted in the event of an emergency?
Name: ___________________________________________ Relationship: _____________________
Day Phone: (________) _________-_________ Evening Phone: (________) __________-__________
REV (5/05)
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