FTC New Member Application

First name*

Last name*

Email*

Phone*

Date of Birth*

Month

Day

Year

Address*

City, State, Zip*

Membership Type*

Employer*

Occupation/Job Title *

Have You Ever Been Arrested?*

Yes

No

If Yes Please Explain *

Have you ever been treated for Mental Illness?

Yes

No

Do you certify that you do not have a Restraining Order or Protective Order issued against you?

Yes

No

Do you certify that you have never been convicted of a felony?*

Yes

No

Do you certify that you are not an unlawful user or distributor of any illegal drugs?

Yes

No

FOID Card #:

FOID Card Expiration Date:

Month

Day

Year

Who referred you to the FTC?

I Have Read & Agree To:

Code of Conduct

Evanston, IL. 60201

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