Philippine Coast Guard Auxiliary Application Form Page 2
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4MA – 2009 Page 2 of 4
MEMBERSHIP APPLICATION
SECTION V – EMERGENCY CONTACT INFORMATION
LAST NAME
FIRST NAME
MI
SUFFIX
RELATIONSHIP
ADDRESS
TEL NO. (HOME)
TEL NO. (BUSINESS)
MOBILE PHONE NO.
SECTION VI – READINESS INPUT
A. FUNCTIONS YOU WANTED TO BE INVOLVED IN: (Please check choice/s)
( ) MARSAR – Maritime Search and Rescue
( ) MAREP – Marine Environmental Protection
( ) MARSAF – Maritime Safety
( ) COMREL – Community Relations (Civic action activities i.e. Medical/Dental Missions;
Youth development)
B. ANSWER B1 AND CHECK APPROPRIATE ANSWERS FOR B2 TO B4:
1. What is your purpose in joining the PCGA? (in at least 50 words you may use separate sheet)
2. Are you willing to be trained? ( ) Yes
( ) No
3. Are you willing to travel outside of your home area? ( ) Yes
( ) No
4. Are you available on call 24 hours? ( ) Yes
( ) No
If No, need ______days/advance notice
SECTION VII – ASSETS/RESOURCES AVAILABLE TO PCGA PROJECTS
(This data will be used for reference as available resources in times of disaster/emergency only and does not mean a full turn-
over to PCG/PCGA of said items/equipment)
ITEMS/CLASSIFICATION
QUANTITY
DESCRIPTION
WATERCRAFT (Boat)
Name ________________________ Type____________________
Speed________________________Power___________________
Range_____________Full Capacity (Ltrs/Gals)________________
AIRCRAFT
LAND TRANSPORTATION
AMBULANCE/FIRETRUCKS
OTHER EQUIPMENTS (Please specify) i.e. Communications: Telephone, 2-way radios, generators, etc.
MANPOWER (Please specify-Doctors/Dentists/Nurses/Support Staff, etc)
SECTION VIII – ORGANIZATIONS
LIST OF ORGANIZATIONS OR SOCIAL GROUPS WHICH YOU HAVE BEEN A MEMBER OF:
ORGANIZATION
PLACE
DATE OF MEMBERSHIP
POSITION HELD
SECTION IX – REQUIRED CLEARANCES and ATTACHMENTS
a. NBI CLEARANCE
a. NBI CLEARANCE
b. POLICE CLEARANCE
b. POLICE CLEARANCE
c. BARANGAY CLEARANCE
c. BARANGAY CLEARANCE
d. ORIENTATION SEMINAR CERTIFICATE (copy)
d. ORIENTATION SEMINAR CERTIFICATE (copy)
(All of the listed Items must be included with the application package)
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