WILLING TO SERVE FORM
City of Half Moon Bay
501 Main Street * Half Moon Bay * California 94019
COMMISSION/COMMITTEE APPLYING FOR:
MEDICAL RESERVE CORPS _________
DISASTER PREPAREDNESS COUNCIL _________
INFORMATION PROVIDED ON THIS APPLICATION IS PUBLIC INFORMATION AND MAY BE MADE AVAILABLE TO OTHER APPLICANTS, MEMBERS OF THE PRESS, OR THE GENERAL PUBLIC.
NAME: ______________________________________ PHONE: ___________________
(PLEASE PRINT)
ADDRESS: ____________________________ CITY: ________________ ZIP: ______
EMAIL ADDRESS: ________________________________________________
PRESENT EMPLOYER: ___________________________
POSITION: _______________________________________
PERSON TO CONTACT IN THE EVENT OF AN EMERGENCY:
NAME _______________________________
CONTACT NUMBER _____________________
____________________________________________ _______________
SIGNATURE DATE | 
