ࡱ> ` bjbj HHHHHHHt 4BD!%%%%13|75oAqAqAqAqAqAqA$6ChEAH5c.155AHH%%:B7775 H%H%oA75oA77w;hHH#<%8! PSk6:;K<$PB0B;4@F;6@F #<@FH#<(55755555AA7 555B5555HHHHHH:B APPLICATION FOR SENIOR MEMBER ACTIVITIES Note: Use of this form is optional (see CAPR 50-17, para 2-7b2). See instructions on reverse. 1. Title of Activity (If applying for a position, include the position desired) 2. Location of Activity FORMTEXT       FORMTEXT      3. Dates of Activity4. Previously Attended This Activity? FORMTEXT       FORMCHECKBOX  No  FORMCHECKBOX  Yes (if yes, give date)  FORMTEXT       5. Last Name, First, Middle Initial6. CAP Grade7. CAPID FORMTEXT       FORMTEXT       FORMTEXT       8. Member s Address (Include No., Street, City, State, Zip) FORMTEXT       FORMTEXT       FORMTEXT      9. Telephone (Include Area Code)Work ( FORMTEXT     )  FORMTEXT      Home ( FORMTEXT     )  FORMTEXT      E-Mail  FORMTEXT       10. Charter Number11. Unit Name12. Date and Method of Level I Completion FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT      13. Date Joined CAP14. CAP Duty Assignment and Inclusive Dates15. CAP Aeronautical Rating FORMTEXT       FORMTEXT       FORMTEXT       16. Specialties and Ratings CompletedSpecialtyRatinga.  FORMTEXT       FORMTEXT      b.  FORMTEXT       FORMTEXT      c.  FORMTEXT       FORMTEXT      d.  FORMTEXT       FORMTEXT      17. Previous Training Activities and Years Attendeda.  FORMTEXT      b.  FORMTEXT      c.  FORMTEXT      d.  FORMTEXT      e.  FORMTEXT       18. Professional Development Awardsa.  FORMTEXT      b.  FORMTEXT       c.  FORMTEXT      d.  FORMTEXT      19. Scholastic AchievementHigh School Graduate (Year):  FORMTEXT        FORMTEXT      College (Number of Years):  FORMTEXT        FORMTEXT      Post Graduate (Number of Years):  FORMTEXT        FORMTEXT       20. Civilian Occupation21. Emergency Medical Information FORMTEXT       FORMTEXT      22. Outline Personal and Professional Goals in CAP FORMTEXT      23. Remarks (Use Reverse Side or Attach Additional Sheet if Necessary)Applicant s Signature and Date FORMTEXT       FORMTEXT      24. Unit Commander (if required) Unit Commander s Signature and DateRecommend  FORMCHECKBOX  Approval  FORMCHECKBOX  Disapproval FORMTEXT      Remarks:  FORMTEXT      25. Wing Commander (if required) Wing Commander s Signature and DateRecommend  FORMCHECKBOX  Approval  FORMCHECKBOX  Disapproval FORMTEXT      Remarks:  FORMTEXT      26. Region Commander (if required) Region Commander s Signature and DateRegion  FORMTEXT      Selection Number  FORMTEXT       FORMTEXT      Recommend  FORMCHECKBOX  Approval  FORMCHECKBOX  DisapprovalRemarks:  FORMTEXT      CAP FORM 17, MAR 03 PREVIOUS EDITIONS WILL NOT BE USED AFTER 30 JUN 03 OPR/ROUTI)    $ & ( 2 4 6 8    * , . 0 ٭Н٭Ѝ٭ЅzojhJrUjThJrUjhxVUjhxV5CJU\jhxV5CJU\$jhJr5CJU\mHnHujhxV5CJU\hxV5CJ\jhxV5CJU\hxV@CJhxV@CJ hxVCJhxV+) 6 <$If h<$IfGkd$$Ifs04'4 sa<$If $ d<<a$6 8 d TJkd4$$Ifs40'74 saf4 <$If h<$IfGkd$$Ifs04'4 sa0 ^ ` b v x z     " , . 0 2 F H J T V X Z n p r | ~ ~hxV@CJ hxV5\jhxV5CJU\jhxV5CJU\j2hxV5CJU\$jhJr5CJU\mHnHuj<hxV5CJU\hxV5CJ\jhxV5CJU\hxV hxVCJ-   0 X AZkd\$$IfsF4'    4 sa <$If h<$IfJkd$$Ifs40'74 saf4X * R9kd\$$Ifs#dA4 sa<$If<Zkd$$IfsF4'    4 sa <$If      & ( , . 0 D F H R T X Z \ p r t ~  פה׎~zjj hxV5CJU\hxVjhxVCJUmHnHu hxVCJj hxV5CJU\j hxV5CJU\$jhJr5CJU\mHnHujhxV5CJU\hxV5CJ\jhxV5CJU\$jhxV5CJU\mHnHu'* , V X I9kd $$Ifs#dA4 sa9kd$ $$Ifs#dA4 sa<$If9kd@ $$Ifs#dA4 sa 02I9kd $$IfsLadO4 sa9kd $$IfsLadO4 sa<$If9kdv $$IfsLadO4 sa ",.24<>@BVXZ`bnprtvƶƜƌƶ|ƬljhxV5CJU\jhxV5CJU\j hxV5CJU\j4 hxV5CJU\hxV hxVCJjhxVCJUmHnHuhxV5CJ\$jhJr5CJU\mHnHujhxV5CJU\jU hxV5CJU\*r <$If h<$If9kd$$IfsLadO4 sartznnbb <$If h<$Ifkdh$$Ifs4F4'/x0    4 saf4"$&(<>}mjhxV5CJU\jhxV5CJU\jhxV5CJU\ hxVCJhxVjhxV5CJU\jqhxV5CJU\$jhJr5CJU\mHnHujhxV5CJU\jhxV5CJU\hxV5CJ\*@znbb <$If h<$Ifkd]$$Ifs4F4'/x0    4 saf4&N}qee <$If h<$Ifkdz$$IfsF'/ 0    4 sa>@JLNR "$&*.0DFHRTVXZnprҼ֬֙։Ҽy֙ij,hxV5CJU\jhxV5CJU\jhxV5CJU\$jhxV5CJU\mHnHuj$hxV5CJU\jhxVCJUmHnHu hxVCJhxVhxV5CJ\$jhJr5CJU\mHnHujhxV5CJU\)NPR}um0<kd $$Ifs44 saf4<$If h<kd$$IfsF'/ 0    4 sa"$VGOkd$$Ifs40 g 4 saf4<$IfOkd~$$Ifs40 g 4 saf4 A$If^A$Ifr|~ *,.8:<>׽׭ӝ׍zjjPhxV5CJU\$jhxV5CJU\mHnHujhxV5CJU\jhxVCJUmHnHujhxV5CJU\jHhxV5CJU\ hxVCJhxVhxV5CJ\jhxV5CJU\$jhJr5CJU\mHnHu)<WOkd4$$Ifs40 g 4 saf4<$IfOkd$$Ifs40 g 4 saf4<>j-<kdQ$$Ifs44 saf4<kdl$$Ifs44 saf4<$IfOkd$$Ifs40 g 4 saf4 246@BDFJNPdfhrtvx|}j!hxV5CJU\j hxV5CJU\jhxV5CJU\jhxVCJUmHnHu$jhJr5CJU\mHnHujhxV5CJU\jhxV5CJU\hxV5CJ\ hxVCJhxV0DFvx}@<kd"$$Ifs44 saf4<kd!$$Ifs44 saf4<kd6 $$Ifs44 saf4<$If *,.048:NPR\^jlnrvx¼¬Ɯ¼ƌ¬|¬j%hxV5CJU\j$hxV5CJU\j#hxV5CJU\jhxVCJUmHnHu hxVCJhxVhxV5CJ\$jhJr5CJU\mHnHujhxV5CJU\jo"hxV5CJU\-.0`x>9kd8$$$Ifs#4 sa 9kdT#$$Ifs#4 sa <$If h<<kd"$$Ifs44 saf4`bdfhjl9kd&$$Ifs#4 sa 9kd%$$Ifs#4 sa <$If JL`bdnprt "$fh|¼¼ƬƜ¼ƌ|¼j)hxV5CJU\j)hxV5CJU\j1(hxV5CJU\j'hxV5CJU\ hxVCJhxVhxV5CJ\$jhJr5CJU\mHnHujhxV5CJU\jn&hxV5CJU\,r"F<kd($$Ifs4#4 sa f49kdR'$$Ifs#4 sa <$If9kd&$$Ifs#4 sa "$}@><kd+$$Ifs4#4 sa f4<kd]+$$Ifs4#4 sa f4<$If<kd*$$Ifs4#4 sa f4|~68:NPR\^`bvxz  8ƶƲƲƜƌƲƲ|ƲthxV@CJj/hxV5CJU\j^-hxV5CJU\j,hxV5CJU\ hxVCJhxVj*hxV5CJU\hxV5CJ\$jhJr5CJU\mHnHujhxV5CJU\jq*hxV5CJU\-68`wmg$If h$Ifskd;,$$Ifs  0'0  4 sa<$If h<$Ifckds.$$Ifs4  '8(0  4 saf4<$Ifskd-$$Ifs  0'0  4 sackd/$$Ifs4  '8(0  4 saf4<$If,.0:<>@  ">@BZ\푇wg^hY5CJ\j3hJrhJrCJUjD3hJrhJrCJUjhYCJU hYCJjZ1hY5CJU\hY5CJ\jhY5CJU\$jhJr5CJU\mHnHuj0hxV5CJU\jhxV5CJU\hxV hxVCJhxV5CJ\$><$Ifvkd#0$$Ifs4  04'0  4 saf4>@|t<$If $ <$Ifvkd1$$Ifs4  04'0  4 saf4\zr<$If  <$Ifvkd2$$Ifs4  04'0  4 saf4\^rtvPRTln¼¦yij-8hJrhJrCJUj7hJrhJrCJUjhYCJU hYCJhxVhxV5CJ\ hxVCJj5hY5CJU\ hYCJhY$jhJr5CJU\mHnHuj,4hY5CJU\hY5CJ\jhY5CJU\"|t<$If <$Ifvkd4$$Ifs4  04'`0  4 saf4 R|t<$If $ <$Ifvkd6$$Ifs4  04' 0  4 saf4RT zr<$If  <$Ifvkd6$$Ifs4  04'0  4 saf4   468BDHJ  <>RTV`bdfz|~¼Ƭ¦Ɖyij<hY5CJU\jF<hY5CJU\j;hY5CJU\hxVhxV5CJ\ hxVCJj9hY5CJU\ hYCJhYhY5CJ\$jhJr5CJU\mHnHujhY5CJU\j8hY5CJU\)  FH|t<$If <$Ifvkd9$$Ifs4  04'`0  4 saf4HJ|t<$If $ <$IfvkdU:$$Ifs4  04' 0  4 saf4dxld<$If <$If h<$If^hvkd ;$$Ifs4  04'0  4 saf4ug_<$If  <$Ifkd4=$$Ifs4  F4'{,`0      4 saf4 24HJLVX\ FLNbdfprx̄~zxzzh~za hxV5\jiBhxV5CJU\UhxV$jhJr5CJU\mHnHuj?hxV5CJU\hxV5CJ\jhxV5CJU\ hxVCJhYhY5CJ\ hYCJj>hJrhJrCJUj:>hJrhJrCJUjhYCJU hYCJ# Z\|t<$If <$Ifvkd"?$$Ifs4  04' 0  4 saf4\^}w$If    $Ifvkd`@$$Ifs4  04'0  4 saf4NG: ETP 27. Additional Remarks: FORMTEXT       INSTRUCTION FOR COMPLETION OF CAP FORM 17 NOTE: Use of this form is optional at the discretion of the activity director (see CAPR 50-17, para 2-7b2). See CAPR 50-17, CAP Senior Member Professional Development Program, for additional information and instructions. 1. APPLYING FOR ACTIVITIES: For region level activities, unit commander verifies the information, makes recommendation, signs the application, retains a copy, and forwards the original to wing headquarters. Wing commander verifies application, makes recommendation, signs the application, retains a copy, and forwards the original to region headquarters for final approval by region commander. For selected national level activities, unit commander verifies the information, makes recommendation, signs the application, retains a copy, and forwards the original to wing headquarters. Wing commander verifies application, makes recommendation, signs the application, retains a copy, and forwards the original to region headquarters for action (if applicable). Region commander makes recommendation, assigns selection number, signs the application, retains a copy, and forwards original to NHQ CAP/ETP. 2. COMPLETING THE FORM: Blocks 1-11, 13-15, 19-20 are self explanatory. Block 12. Enter the month and year and method of Level I completion. (Example: Feb 92/Seminar or Mar 93/ Mitchell Award.) Block 16. List each specialty and the highest rating completed in that specialty. (Example: Enter 213-2 for Emergency Services Officer - Senior Level, or enter 201-1 for Public Affairs - Technician Level.) Block 17. List names and dates of training activities such as SAR exercises, SLS, AFIADL Course-13, RSC, ACSC, AWC, etc. Use Additional Remarks section above or add additional sheet if necessary. Block 18. List training awards only along with completion dates. (Example: Garber Award Aug 90.) Block 21. List physical handicaps or ailments for which the applicant will be taking medication during the activity or which might affect the applicant s level of participation in activities. Provide a list of medication taken regularly. Use Additional Remarks section or add additional sheet if necessary. Block 24. For Unit Commander. Remarks are intended for consideration by the wing commander. Use Additional Remarks section or add additional sheet if necessary. Block 25. For Wing Commander. For National Staff College (NSC), wing commander approves for personnel assigned within their wing, then forwards to NHQ CAP/ETP. Use Additional Remarks section or add additional sheet if necessary. Block 26. For Region Commander. For National Staff College (NSC), this block is completed by region commander only for those members currently serving on the region staff, and then forwarded to NHQ CAP/ETP. Remarks are intended for consideration by National Headquarters. Use Additional Remarks section or add additional sheet if necessary. 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