St. Clair County Hazardous Operations Team Application

        First Name                   Middle Name                 Last Name
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? 

Position Applying For:
   

Primary Availablity: 

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?

 
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
1:
2:
3:
4:
5:

   



Contact Information

Office of Homeland Security / Emergency Management
295 Airport Drive
Kimball, MI 48074

Phone: (810) 989-6965
Fax: (810) 364-4603
Email: Emergency Management