Steuben County Emergency Services

Steuben County Emergency Services

ID Request Form

Original Application
Change Request (enter required information and only info that has changed. * indicates required fields.)

*Date of Application/Renewal:

*Last Name:*First Name: Middle Initial:

*Organization: Agency Hire Date: Driver License#:

APPLICANTS CONTACT INFORMATION

Phone #1: Cell Home Work Other ______(check one)

Phone #2: Cell Home Work Other ______(check one) Phone #2: Cell Home Work Other ______(check one)

Email:

Email 2:

APPLICANTS ADDRESS INFORMATION

*Address (mailing):

City: State: Zip:

*Address (physical):

City: State: Zip:

APPLICANTS DEMOGRAPHIC INFORMATION

Gender:Weight:

Race: DOB:

Height:Blood Type:

Hair: Eyes:

APPLICANTS MEDICAL/EMERGENCY INFORMATION

Medical Alerts:

Emergency Contact Name #1: Phone 1st: Phone2nd:

*****PLEASE MAKE SURE YOU PRINT/COMPLETE THE SECOND PAGE TO THIS DOCUMENT****

*APPLICATION CONTINUED*
*Last Name:*First Name: Middle Initial:

APPLICANTS MISCELLANEOUS INFORMATION

ICS Level:

Steuben County Emergency ServicesPage 1 of 2Steuben ID Request Form Rev.3 10-19-15

Steuben County Emergency Services

ID Request Form

Fire Block: Exterior FirefighterInterior FirefighterNon FirefighterPump OperatorRookie FirefighterDFCFCFI

EMS Block: Non EMSCPRDriverFirst ResponderEMTEMT-IEMT-CCParamedicEMS C

Law Enforcement: Non Law EnforcementFire PoliceDeputyTrooperOfficerDetectiveSupervisor

Special Certifications: NoneAdvanced ICSConfined SpaceHaz Mat OpsHaz Mat SpecialistHazmat TechnicianIce ResQResQ TechRITRope ResQSafety OfficerSFISwiftOther

Steuben County Emergency ServicesPage 1 of 2Steuben ID Request Form Rev.3 10-19-15

Steuben County Emergency Services

ID Request Form

Note, if updating Classifications, please update all 4 classifications.

For firefighters, enter TIMS (Training ID #)

For EMS,(EMT, Paramedic) enter certification number: Expiration date of the certification:

Steuben County Emergency ServicesPage 1 of 2Steuben ID Request Form Rev.3 10-19-15

Steuben County Emergency Services

ID Request Form

Rank: FirefighterEmergency Medical ServicesChiefAsst ChiefLuetenantCaptainExpiration Date: (for elected officers)

Steuben County Emergency ServicesPage 1 of 2Steuben ID Request Form Rev.3 10-19-15

Steuben County Emergency Services

ID Request Form

Check All that Apply:

Steuben County Emergency ServicesPage 1 of 2Steuben ID Request Form Rev.3 10-19-15

Steuben County Emergency Services

ID Request Form

FF Essentials of FiremanshipEF

FF Firefighter 1FF1

FF Firefighter 2FF2

FF Firefighter BasicFFB

FF Firefighter IntermediateFFI

FF Firefighter AdvancedFFA

FF Firefighter Scene SupportFSS

Confined Space AwarenessCSA

Confined Space Rescue TechnicianCSRT

Fire Apparatus Driver/OperatorFADO

Fire Officer 1FOI

Fire Officer 2FOII

Fire Officer 3FOIII

Fire PoliceFP

HazMat AwarenessHMA

HazMat OperationsHMO

HazMat TechnicianHAZT

HazMat SpecialistHAZS

High Angle RescueHAR

Ice RescueIR

Low Angle RescueLAR

Rapid Intervention TeamRIT

Rope Rescue TechnicianRRT

Safety OfficerSO

Swiftwater/Flood Rescue TechnicianSFRT

Trench Rescue TechnicianTRT

Vehicle ExtricationVEHX

Wilderness Search & Rescue TechWSRT

Weapons of Mass Destruction AwareWMDA

EMS Certified First ResponderCFR

EMS Driver (Emergency Vehicle)EVO

EMT BasicEMT

EMT IntermediateEMTI

EMT Critical CareEMTCC

EMT ParamedicEMTP

ICS100 IntroductionICS100

ICS200 Incident Command SystemICS200

ICS300 IntermediateICS300

ICS400 AdvancedICS 400

ICS Incident Commander QualifiedIC

Industrial Fire BrigadeIFB

Steuben County Emergency ServicesPage 1 of 2Steuben ID Request Form Rev.3 10-19-15

Steuben County Emergency Services

ID Request Form

MISCELLANEOUS COMMENTS:

AS APPLICANT I HEREBY CERTIFY THE ABOVE INFORMATION TO BE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. AS FIRE CHIEF I HEREBY CERTIFY THE ABOVE INFORMATION IS TRUE AND CORRECT AND I FURTHERMORE APPROVE THE PRINTING OF THE ID BADGES FOR THIS APPLICANT.

Wayne County Emergency ManagementPage 1 of 2ID Request Form Rev. 1