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St. Clair County Hazardous Operations Team Application


Last Name
First Name
Middle Name

Social Security #
Street Address
City

State
Zip
Home Phone

Work Phone
Email 		 

 

Position Applying For:  
80 Hour Advanced Technician 40 Hour Rescue Technician/Entry Support
Current Employer Business Phone
Position/Duites   May we contact employer?
Primary Availablity: Days Afternoons Midnights
Previous Hazardous Materials Experience:
List Three Professional References:  
Name Phone
Name Phone
Name Phone
Driver's License Number:
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    No
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 (Name): Date:
Please attach copies of all certificates to this application before submitting

 


Contact Information

Office of Homeland Security / Emergency Management
200 Grand River, Suite 204
Port Huron, MI 48060

Phone: (810) 989-6965
Fax: (810) 989-6908
Email: emergencymanagement@stclaircounty.org
 
St. Clair County, Michigan

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