Shepherd Park Plaza Civic Club
Deputy Constable Patrol Contract
Participation Application
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 $175.
{ } Attached is my contribution in the amount of $ _________________________.
{ } I/we can not contribute $175 at this time. However, I/we can contribute $_________.
Make checks payable to SPP Civic Club.
Return to: Jim Worthing, 1029 Richelieu Houston, Texas 77018