Shepherd
Park Plaza Civic Club
Deputy Constable Patrol Contract
Participation Application
Please print this
page, enter your information and return it with your check to the address
listed below
PLEASE PRINT OR WRITE LEGIBLY
NAME: _________________________________________________________________
SPOUSE:
_______________________________________________________________
ADDRESS:
_____________________________________________________________
HOME PHONE:
_________________________________________________________
HIS WORK PHONE:
_____________________________________________________
HER WORK PHONE:
_____________________________________________________
OTHER WAYS TO CONTACT YOU: (please use extra sheet to provide any information
you think would be helpful)
HIS CELL PHONE: ___________________ HER CELL
PHONE: _________________
EMAIL ADDRESS:
______________________________________________________
DO YOU WANT TO RECEIVE EMAIL ALERTS? { } YES
{ } NO
(Below please give us the name(s) and
number(s) of a relative, friend, or neighbor to contact in case of an
emergency)
EMERGENCY CONTACT #1:
______________________________________________
EMERGENCY CONTACT #1 PHONE:
______________________________________
EMERGENCY CONTACT #2:
______________________________________________
EMERGENCY CONTACT #2 PHONE:
______________________________________
ALL
INFORMATION IS HELD STRICTLY CONFIDENTIAL
{ } Attached is my contribution of $250.
{ } Attached is my contribution in the amount
of $ _________________________.
{ } I/we can not
contribute $250 at this time. However, I/we can contribute $_________.
Make checks payable to SPP Civic Club.
Return to: PhilipBilleaud, 1107 Chamboard Ln, Houston, Texas 77018