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Hair Color:
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Armed Forces Americas
Armed Forces Europe
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Do you currently have or have received treatment in the past 5 years for any of the following:
Back Injury:
Yes
No
Epilepsy:
Yes
No
Heart Disease:
Yes
No
Diabetes:
Yes
No
Hypertension:
Yes
No
Have you ever been arrested or had a civil judgement brought against you?
Yes
No
Employer:
Position:
Employer Address:
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Zip:
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List how you wish to be reached for activation:
Will your employer allow you to respond during work hours?
List Three Character References:
1. Name:
Address:
Phone:
2. Name:
Address:
Phone:
3. Name:
Address:
Phone:
High School Graduate:
Yes
No
College Years:
Degree:
Yes
No
Field of Study:
Professional Certifications:
Occupational Skills:
Public Safety Training:
Public Safety Training:
CPR / AED Training:
Emergency Contact Information
Name:
Relationship:
Home Phone:
Mobile Phone:
E-Signature
I agree
I do affirm that the information above is true and correct. Any falsification of this information will be grounds for rejection of this application, should an investigation reveal a deliberate attempt to mislead the Covington County Emergency Management Agency. I further agree to comply with all policies and procedures of the Covington County Emergency Management Agency. Any violation of policies and procedures will result in administrative action and possible dismissal as a volunteer. I understand that information contained herein is of a confidential nature and that it is to be used for Emergency Management business only. I authorize Covington County Emergency Management Agency officials to use this information to conduct a criminal background examination should it be deemed necessary.
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