St. Clair County

Hazardous Operations Team Application

St. Clair County Hazardous Operations Team Application

Name:

Address:

City:

State:

Zip:

Phone:

Work Phone:

Date of Birth:

Driver's License #:

Social Security #:

Email Address:

Current Employer:

Position / Duties:

Business Phone:

May we contact your employer?

Yes

Position Applying For:

80 Hour Advanced Technician

40 Hour Rescue Technician / Entry Support

Primary Availability:

Days

Afternoons

Midnights

Previous Hazardous Materials Experience:

List Three Professional References:

Name:

Phone:

Name:

Phone:

Name:

Phone:

Have you had any medical history that would limit or prevent you from taking part in any physical exertion? If yes, please explain:

Are you willing to commit a minimum of 5 hours per month to the team?

Yes

I agree to submit: To records search by a law enforcement agency in order to determine
if I have any serious criminal record or driving record.

ALL INFORMATION WILL BE KNOWN TO LAW ENFORCEMENT ONLY.

Signature:

Date:

Hazardous Operations Team Application

St. Clair County Hazardous Operations Team Application

Submission Sent

I agree to submit: To records search by a law enforcement agency in order to determine
if I have any serious criminal record or driving record.

ALL INFORMATION WILL BE KNOWN TO LAW ENFORCEMENT ONLY.

Please attach copies of all certificates to this application before submitting.

Office of Homeland Security / Emergency Management

St. Clair County Hazardous Operations Team Application

Submission Sent

I agree to submit: To records search by a law enforcement agency in order to determine if I have any serious criminal record or driving record.

ALL INFORMATION WILL BE KNOWN TO LAW ENFORCEMENT ONLY.

Please attach copies of all certificates to this application before submitting.

Office of Homeland Security / Emergency Management

I agree to submit: To records search by a law enforcement agency in order to determine
if I have any serious criminal record or driving record.