The Person I Admire

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  • Topic: Government agency, Authorization, Business
  • Pages : 6 (833 words )
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  • Published : February 11, 2013
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MAYOR’S OFFICE OF EMERGENCY MANGEMENT

EMERGENCY OPERATIONS CENTER

Volunteer ESU Application

Please print or type all information clearly.

This application is required for membership and must be filled out in its entirety, including the background authorization form at the end.

NAME:               
LASTFIRSTMIDDLE

HOME ADDRESS:                    
STREETCITYSTATEZIP

BUSINESS NAME/ADDRESS:     

                     STREETCITYSTATEZIP

HOME PHONE:       WORK PHONE:      PAGER/CELL:      

ARE YOU OVER THE AGE OF 21 YEARS? YES NO

ARE YOU A US CITIZEN OR AUTHORIZED TO BE IN THE UNITED STATES? YES NO Non-citizens may be required to present current resident alien card.

HAVE YOU EVER BEEN CONVICTED OF A DUI, DWI OR SUBSTANCE ABUSE? YES NO

WOULD YOU AGREE TO SUBMIT TO A DRUG TEST AT ANY TIME DURING YOUR MEMBERSHIP IF REQUESTED? YES NO

HAVE YOU EVER BEEN CONVICTED OF VIOLATION OF THE LAW OTHER THAN MINOR TRAFFIC OFFENSES? YES NO

IF YES, PLEASE EXPLAIN:

          

DRIVERS LICENSE NUMBER:     STATE:     

MILITARY SERVICE:BRANCH       RANK AT DISCHARGE      

PRESENT STATUS      

HIGHEST GRADE COMPLETED IN SCHOOL:     

DO YOU HAVE ANY PRIOR EXPERIENCE IN RESCUE WORK? YES NO

IF YES, PLEASE FILL OUT THE FOLLOWING:

NAME OF AGENCY      CITY AND STATE      

LENGTH OF MEMBERSHIP      NAME OF SENIOR OFFICER      

TELEPHONE NUMBER OF SENIOR OFFICER     

WERE YOU:DISMISSED PLACED INACTIVE TRANSFERRED RESIGNED OTHER REASON      

LIST ALL SPECIAL TRAINING COURSES THAT YOU HAVE TAKEN. IF YOU ARE CURRENTLY CERTIFIED, WRITE THE EXPIRATION DATE BESIDE THE COURSE.

(EMT, CPR)     

LIST YOUR PAST THREE EMPLOYERS BEGINNING WITH THE MOST RECENT

|DATE WORKED |COMPANY NAME , ADDRESS |IMMEDIATE SUPERVISOR | |MONTH AND YEAR |AND PHONE NUMBER |TO BE CONTACTED | | |      |      | |      | | | | | | | | |      |      | |      | | | | | | | | |      |      | |      | | | | | | |

PLEASE LIST THREE PERSONAL CHARACTER REFERENCES OTHER THAN RELATIVES.

|NAME |ADDRESS |TELEPHONE NUMBER |...
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