U.S. Citizen :  Yes       No      Binoculars   Yes     No

Concealed weapons Permit   Yes       No

Video Camera    Yes   No   

Will you go on border Watch ?   Yes       No

(If Yes) How long?

Will you support in other ways?  Yes    No 

Any disabilities? (describe)   

Other comments/suggestions

Emergency Contact (include phones #):

          Liability Release After verification, we will build a mailing list with the above information. General information will be on the website but other information will be for members only via email. I understand that North Carolina Minuteman Patriots (NCMMP) is not a club or militia but an gathering of like minded people via the website and email to bring peaceful change. I understand that the actions of one independent NCMMP agent is not the reponsibility of others associated by NCMMP. I understand I will be working with many uncover police officers and I maybe arrested if I break the law. I agree to a background check. I waive any right to sue the NCMMP management, or any group or volunteer in any state working with NCMMP for any reason, or others with the NCMMP for accidents injuries, or assaults. NCMMP is not responsible for my medical bills. I further waive any right to sue or demand money from any land owner in any way helping NCMMP by allowing use of their land. I operate and associate with NCMMP and those related to NCMMP at my own risk. I assume all liability and responsibility for myself and my family. I am an independent agent and not a employee. I understand that I am automatically disassociated with the NCMMP if I get abusive or exessively argumentative, break a NCMMP rule, or standard operating procedure, or break a local, state or federal law. I execute this understanding and waiver of liability. Note: When we meet in person you will be asked to sign the liability form and it will be stamped by a notary public. We must protect each other,ourselves and friendly ranchers. Selecting I agree and clicking the submit button below indicates your assurance that: 1. The information you have supplied is true and accurate. 2. You consent to NCMMP verification of the supplied information. 3. You agree with and execute the above Liability Release.                     

                                  I Agree