Application for Membership

PERSONAL INFORMATION

Name:

Birthday*

Spouse/Partner's Name (if applicable)

Ages/# of Children (if applicable)

Address:

Telephone (Home)

Telephone (Cell)

E-Mail Address

Length of Residence in the Area

Previous Residence Area

WORK EXPERIENCE

Current:

Past:

Affiliations: (Social, Professional, Service Clubs Organizations and offices held...)

REFERENCES

Do you know any EMQ Auxilliary or Butter Paddle Members?

Members Name:

Why are you interested in being a member of the EMQ Auxilliary/Butter Paddle Volunteer? (400 chars left)

Covid-19 Vaccination Status

Santa Clara County requires all business to provide affidavits of vaccination status of their employees/volunteers and as such, prospective members will be required to complete a Certification of Vaccination Status form as part of the application process. Please note that as of February 2022, we are requiring all new members to be fully vaccinated for the health and safety of our membership.

Covid-19 Vaccination Status I am fully vaccinated against Covid-19
I am not vaccinated
I prefer not to say

SIGNATURE

Applicants Signature

OFFICIAL AREA

Membership Chair

Date Received