Cap Form 83 - Civil Air Patrol Counterdrug Application
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1
2CIVIL AIR PATROL COUNTERDRUG APPLICATION
INSTRUCTIONS: Fill in all items. If the answer is "no" or "none", so state. If additional space is needed,
use an additional sheet of paper. Form must be typed or computer generated.
1. DATE
2. CHARTER
3. CREW POSITION:
(MMM/DD/YY):
(I.E., VA123):
4. NAME
:
5. IF KNOWN BY OTHER NAME, SPECIFY:
(LAST/ FIRST/M.I.)
6. TYPE APPLICATION:
7. CAPID:
8. SSAN:
INITIAL
RE-CERTIFICATION
9. HOME PHONE:
10. BUSINESS PHONE:
RE-APPLICATION
11. PLACE OF BIRTH
:
12. DATE OF BIRTH
13. GENDER:
(CITY & STATE)
(MMM/DD/YY)
:
MALE
FEMALE
14. DRIVER’S LICENSE NUMBER:
STATE:
15. LIST RESIDENCES DURING THE LAST 3 YEARS BELOW, IN REVERSE ORDER. BEGIN AT THE TOP WITH YOUR
PRESENT ADDRESS. ZIP CODE IS ONLY REQUIRED FOR THE PRESENT ADDRESS. POST OFFICE BOX OR
RURAL ROUTE IS NOT ACCEPTABLE.
DATES
(MMM YY)
FROM
TO
NUMBER AND STREET
CITY
COUNTY
STATE
PRESENT
ZIP CODE:
16. HAVE YOU EVER SERVED IN THE U.S. ARMED FORCES
(ACTIVE, RESERVE OR NATIONAL GUARD)
:
Yes
No
IF YES:
CURRENTLY SERVING; OR LIST TYPE DISCHARGE:
17. U.S. CITIZEN
:
YES
(MUST BE A U.S. CITIZEN)
NATURALIZED:
YES CERTIFICATE NO.:
18. CURRENT EMPLOYER:
DATE EMPLOYED
(MMM/DD/YY):
FULL EMPLOYER ADDRESS:
TYPE OF WORK:
19. DO YOU NOW USE, OR HAVE YOU EVER USED, ANY SUBSTANCES LISTED BELOW OR ANY CONTROLLED
SUBSTANCE THAT WAS NOT PRESCRIBED A PHYSICIAN?
NO
YES (If YES, list the substance(s) and explain on separate sheet.)
MARIJUANA
COCAINE
HEROIN
HASHISH
LSD
METHAMPHETAMINE
OTHER SUBSTANCES
LIST EACH:
20. ARRESTS. HAVE YOU EVER BEEN ARRESTED:
YES
NO; TAKEN INTO CUSTODY
YES
NO; HELD
FOR INVESTIGATION
YES
NO; QUESTIONED BY ANY LAW ENFORCEMENT AGENCY
YES
NO.
IF YES, A FULL EXPLANATION, INCLUDING DATE(S), REASON AND OUTCOME, ON A SEPARATE PAGE, IS REQUIRED
CAP FORM 83, FEB 04
PREVIOUS EDITIONS WILL NOT BE USED
OPR/ROUTING: DOS
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