Cap Form 83 – Fill Out and Use This PDF

CIVIL AIR PATROL COUNTERDRUG APPLICATION

INSTRUCTIONS: Fill in all items. If the answer is "no" or "none", so state. If additional space is needed, use an additional sheet of paper. Form must be typed or computer generated.

1.

DATE (MMM/DD/YY):

2. CHARTER (I.E., VA123):

3. CREW POSITION:

4.

NAME (LAST/ FIRST/M.I.):

5.

IF KNOWN BY OTHER NAME, SPECIFY:

6.

TYPE APPLICATION:

7.

CAPID:

8.

SSAN:

INITIAL

RE-CERTIFICATION

RE-APPLICATION

9.

HOME PHONE:

10.

BUSINESS PHONE:

11.

PLACE OF BIRTH (CITY & STATE):

12.

DATE OF BIRTH (MMM/DD/YY):

13. GENDER:

MALE

FEMALE

14.

DRIVER’S LICENSE NUMBER:

STATE:

15.

LIST RESIDENCES DURING THE LAST 3 YEARS BELOW, IN REVERSE ORDER. BEGIN AT THE TOP WITH YOUR

PRESENT ADDRESS. ZIP CODE IS ONLY REQUIRED FOR THE PRESENT ADDRESS. POST OFFICE BOX OR

RURAL ROUTE IS NOT ACCEPTABLE.

DATES (MMM YY)

FROM

TO

NUMBER AND STREET

CITY

COUNTY

STATE

PRESENT

ZIP CODE:

16.

HAVE YOU EVER SERVED IN THE U.S. ARMED FORCES (ACTIVE, RESERVE OR NATIONAL GUARD):

Yes

No

IF YES:

CURRENTLY SERVING; OR LIST TYPE DISCHARGE:

17.

U.S. CITIZEN (MUST BE A U.S. CITIZEN): YES

NATURALIZED:

YES

CERTIFICATE NO.:

18.

CURRENT EMPLOYER:

DATE EMPLOYED (MMM/DD/YY):

FULL EMPLOYER ADDRESS:

TYPE OF WORK:

19.

DO YOU NOW USE, OR HAVE YOU EVER USED, ANY SUBSTANCES LISTED BELOW OR ANY CONTROLLED

SUBSTANCE THAT WAS NOT PRESCRIBED A PHYSICIAN?

NO

YES (If YES, list the substance(s) and explain on separate sheet.)

MARIJUANA

COCAINE

HEROIN

HASHISH

LSD

METHAMPHETAMINE

OTHER SUBSTANCES

LIST EACH:

20. ARRESTS. HAVE YOU EVER BEEN ARRESTED:

YES

NO; TAKEN INTO CUSTODY

YES

NO; HELD

FOR INVESTIGATION YES

NO; QUESTIONED BY ANY LAW ENFORCEMENT AGENCY

YES

NO.

IF YES, A FULL EXPLANATION, INCLUDING DATE(S), REASON AND OUTCOME, ON A SEPARATE PAGE, IS REQUIRED

CAP FORM 83, FEB 04

PREVIOUS EDITIONS WILL NOT BE USED

OPR/ROUTING: DOS

CIVIL AIR PATROL COUNTERDRUG MISSION NONDISCLOSURE AGREEMENT

By signing this form I realize that due to my current affiliation with the Drug Enforcement Administration (DEA), Bureau of Immigration and Customs Enforcement (BICE), and the U.S. Forest Service (USFS), I hereby declare that I intend to be governed by and will comply with the following provisions:

(1)I understand that unauthorized disclosure of information I may acquire as a Civil Air Patrol counterdrug (CD) mission crew member could place human life in jeopardy, or result in the denial of "due process" to a person or persons who are targets of investigations, or prevent the above listed agencies from effectively discharging their responsibilities.

(2)I agree that I will never divulge, publish, or reveal either by word or conduct or by any other means disclose to any unauthorized recipient, any information acquired as part of the performance of my duties as a CD crew member or CD mission coordinator where any such divulgence, publication, revelation or disclosure would be contrary to law, regulation or public policy.

(3)I understand unauthorized disclosure could be a violation of Federal law and subject to prosecution as a criminal offense. I accept the above provisions as conditions for my participation in the CAP CD mission. I agree to comply with these provisions both during my tenure in the CAP CD mission and following termination of such tenure.

(4)I authorize Law Enforcement Agencies to conduct background checks during the screening process.

CIVIL AIR PATROL COUNTERDRUG MISSION STATEMENT OF UNDERSTANDING

Pursuant to the Agreement among the Civil Air Patrol, Drug Enforcement Administration, Bureau of Immigration and Customs Enforcement, U.S. Forest Service and the Air Force, I may be asked to assist the Bureau of Immigration and Customs Enforcement, Drug Enforcement Administration, or U.S. Forest Service by providing and operating CAP aircraft for law enforcement officers who will conduct reconnaissance to detect illegal activity. I understand the dangers that may result from these patrol flights, which might put me in close proximity to armed drug traffickers. However, I agree I will neither possess nor use any weapons while on a counterdrug (CD) mission, nor will I physically participate in arrest or detention procedures or search and seizure of evidence. I further understand that due to the sensitive nature of this mission, a security screening of participating CAP member is required, and I further understand

1.that this form will be submitted to the Drug Enforcement Administration (DEA) and the Bureau of Immigration and Customs Enforcement (BICE) as part of their mandatory screening process;

2.that successful screening by these agencies is required before I will be permitted to perform certain volunteer service for these and other federal agencies;

3.that false statements to federal agencies is a criminal offense under Title 18, United States Code, Section 1001;

4.that furnishing the required information is voluntary, but failure to accurately provide complete information may result in denial of clearance and/or termination of Civil Air Patrol membership; and

5.rejection by either DEA or BICE, for any reason, may result in resubmission of my fingerprints to the FBI for membership screening in accordance with CAPR 39-2.

6.that I authorize submission of this form to DEA and BICE.

APPLICANT SIGNATURE				Date
			(PLEASE SIGN WITH INK) (ORIGINAL SIGNATURE REQUIRED)
WING CDO OR
REGION CDD				Date
			(PLEASE SIGN WITH INK) (ORIGINAL SIGNATURE REQUIRED)
CAP WG/CC OR
CAP REGION CC OR				Date
			(PLEASE SIGN WITH INK) (ORIGINAL SIGNATURE REQUIRED)
			(PLEASE PRINT WING/CC, REGION/CC NAME)
DEA CERTIFICATION				Date
BICE CERTIFICATION				Date

CAP FORM 83, FEB 04

REVERSE