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Contact Information Applicant name First Middle Last Applicant address Address Address 2 City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Business name Business address Address Address 2 City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Home phone Work phone Cell phone / pager Email address Over 21 Yes No Are you over the age of 21 years? U.S. citizenship Yes No Are you a U.S. citizen or authorized to be in the United States? DUI, DWI, substance abuse Yes No Have you ever been convicted of a DUI, DWI, or substance abuse? Drug test Yes No Would you agree to submit to a drug test at any time during your membership if requested? Other convictions Yes No Have you ever been convicted of violation of the law other than minor traffic offenses? If yes, please explain. Driver's license number Driver's license state State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Highest grade completed in school Military Service Branch Rank at discharge Present status Rescue experience Yes No Do you have any prior experience in rescue work? If yes, please fill out the following: Name of agency Agency address Address Address 2 City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Length of membership Name of senior officer Phone number of senior officer Reason for leaving Dismissed Placed inactive Transferred Resigned Other If you selected other, please explain. Training courses List all special training courses that you have taken. If you are currently certified, write the expiration date beside the course. Work History List your past three employers beginning with the most recent. Employer 1 Date worked (month and year) Company name Company address Company phone Immediate supervisor to be contacted Employer 2 Date worked (month and year) Company name Company address Company phone Immediate supervisor to be contacted Employer 3 Date worked (month and year) Company name Company address Company phone Immediate supervisor to be contacted Character References Please list three personal character references other than relatives. Reference 1 Name Address Phone number Reference 2 Name Address Phone number Reference 3 Name Address Phone number Availability If accepted, approximately what hours would you be available? Please use a.m. and p.m. with times. Sunday Monday Tuesday Wednesday Thursday Friday Saturday Unique circumstances Yes No If accepted, are there any unique circumstances we should be aware of to assist you in performing your duties? If yes, please explain. Special accommodations Yes No If accepted, are there any special accommodations you would need to perform your duties? If yes, please explain. How did you find out about the ESU program? What prompted you to join this organization? Certify I hereby acknowledge my complete understanding that the standby assignment I am volunteering for carries with it the requirement that I will, without question, obey and execute to the best of my ability the lawful orders of those designated to supervise and command my activities, that I will complete all assigned training courses, and that any violation or disregard of the rules and regulations of the Emergency Support Unit (ESU) will be cause for disciplinary action or dismissal. Furthermore, I understand that any false statements intentionally made in my application disqualifies me for membership in the Office of Emergency Management, Emergency Support Unit. I understand that in compliance with Tennessee State Law, all applications are subject to public disclosure, and according to T.C.A 47-10-107 (a)(d), Legal recognition of electronic records, electronic signatures, and electronic contracts, a record or signature may not be denied legal effect or enforceability solely because it is in electronic form, and if a law requires a signature, an electronic signature satisfies the law. I have agreed to submit this application by electronic means. By signing this application electronically, I certify that: I understand the questions and statements on this application; My answers are correct and complete to the best of my knowledge; I am the person applying for this position; I authorize the Office of Emergency Management Director, or his designee, to verify the information I have provided in this application; and, I authorize the Office of Emergency Management Director, or his designee, to conduct a records check of my traffic moving violations in Tennessee. By checking this box and typing my name below, I am electronically signing my application. I understand that my electronic signature has the same legal effect as my written signature. Electronic signature First name Middle initial Last name Suffix Leave this field blank