Application

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Oconee County Emergency Management Agency

415 South Pine Street

Walhalla, SC 29691

                                                                      APPLICATION FOR MEMBERSHIP         

                                                                            CONFIDENTIAL INFORMATION

TO WHOM IT MAY CONCERN:                                    DATE                                                                          

I HEREBY APPLY FOR ASSIGNMENT AS A MEMBER OF THE                                                 RESCUE SQUAD DIVISION OF THE OCONEE COUNTY RESCUE SQUAD AND AGREE TO TAKE ALL TRAINING REQUIRED AND TO COMPLY WITH ALL RULES AND REGULATIONS PERTAINING TO THE OCONEE COUNTY RESCUE SQUAD AND THE                                       DIVISION.

                                                                       PERSONAL INFORMATION

NAME                                                      RES. PHONE                                    BUS.PHONE                          

ADDRESS                                                                                  CITY                             STATE                       

AGE             BLOOD TYPE             HEIGHT            WEIGHT               SEX            HAIR COLOR              

BIRTH PLACE                                                                             DATE OF BIRTH                                          

MARITAL STATUS  M              S              D             W                 NO. OF CHILDREN                              

IN CASE OF EMERGENCY CONTACT                                                         PHONE                                   

COMPLETED GRADE                        AT                                                                                                         

COMPLETED YEARS              AT                                                                DEGREE                                   

SPECIAL COURSES OR SCHOOL                                                                                                                

OCCUPATION AND EMPLOYER                                                                                                                    

SOCIAL SECURITY NO.                                          DRIVERS LICENSE NO.                                               

MOTOR VEHICLES OWNED (NO.)              MAKE, MODEL, YEAR                                                           

HOBBIES                                                                                                                                                             

MILITARY SERVICE:   YEARS                    BRANCH                        DISCHARGE                                      

                                        RANK                 RESERVE STATUS                      S.S. CLASS                          

FOREIGN LANGUAGES                           SPEAK                     READ                       WRITE                      

HAVE YOU HAD PREVIOUS OR COMPARABLE EXPERIENCE IN THE SERVICE APPLIED FOR?

YES                  NO                   (IF YES, EXPLAIN ON REVERSE SIDE )

HAVE YOU EVER BEEN ARRESTED OR CONVICTED FOE ANYTHING OTHER THAN MINOR TRAFFIC VIOLATION?  YES                          NO                   (IF YES, EXPLAIN ON REVERSE SIDE)

LIST THREE (3) CHARACTER REFERENCES:

( NO RELATIVES)                                                                                                      OCCUPATION                                               NAME                                     ADDRESS     

1.                                                                                                                                                                           

2.                                                                                                                                                                           

3.                                                                                                                                                                           

I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND THE OCONEE COUNTY RESCUE SQUAD ORGANIZATION RULES AND GUIDELINES AND DO HEREBY AGREE TO OBEY SAID RULES AND GUIDELINES. FURTHER, I HEREBY SPECIFICALLY CONSENT FOR THE RESCUE SQUAD AND/OR THE OCONEE COUNTY EMERGENCY MANAGEMENT AGENCY (EMA) TO INVESTIGATE MY BACKGROUND THROUGH THE NATIONAL CRIME INFORMATION CENTER , SLED AND ANY OTHER LAW ENFORCEMENT AGENCIES WHICH THE EMA OR RESCUE SQUAD DESIRES. I HERBY CERTIFY THAT ALL INFORMATION ON THIS APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE.  I DO HEREBY HOLD OCONEE COUNTY EMA AND OCONEE COUNTY HARMLESS OF ANY LIABILITY, WHETHER CIVIL OR CRIMINAL, THAT MAY ARISE AS A RESULT OF THE RELEASE OF THIS INFORMATION ABOUT ME.  I FURTHER HOLD HARMLESS ANY INDIVIDUAL, AGENCY, BUSINESS, OR CORPORATION THAT PROVIDES INFORMATION AS PART OF ITS VERIFICATION OF MY VOLUNTEER APPLICATION AND PERIODICALLY FOR EVALUATION PURPOSES.

SIGNATURE OF APPLICANT

SWORN TO BEFORE ME THIS             

DAY OF                                     ,  20