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? YesNo

Position Applying For:
80 Hour Advanced Technician 40 Hour Rescue Technician/Entry Support

Primary Availablity: 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? YesNo

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
295 Airport Drive
Kimball, MI 48074