Volunteer Emergency Responder

Dodge County

Membership Application Form

Personal Information
CANDIDATE DEMOGRAPHICS
MIDDLE INITIAL
Date of Birth
Are you a US Citizen?
Do you reside in Dodge County?
Have you ever worked for Dodge County Emergency Response Team Inc.?
BACKGROUND INFORMATION
Have you ever been convicted of a felony, misdemeanor or criminal traffic violation?
Have you ever been charged with a violent crime, domestic abuse, or a sex crime?
Have you ever been convicted of an OWI (Operating While Intoxicated) or DUI (Driving Under the Influence)?
Do you have any felony, misdemeanor or criminal traffic charges pending against you?
Have you been convicted of more than 2 traffic violations in the past 5 years?
Do you have physical or mental limitations that would prohibit you from fulfilling the duties of the position you are applying for? If yes, please explain below.
Do you have an unrestricted and unconditional WI Class D Driver's License?
ADDITIONAL INFORMATION
Do you currently hold a valid Peace Keeper, EMS, TEMS, or Firefighter license with the State of Wisconsin?
Do you currently hold FEMA ICS 100, 200, 700 or WI TIMS Certifications?
Would you be able to obtain the previously listed FEMA and/or WI TIMS certification(s) within your first year?
What is your typical availability to respond to calls for service/assist with events?
VOLUNTARY DISCLOSURES
ACKNOWLEDGEMENTS
Dodge County Emergency Response Team Inc. provides equal membership opportunities to all persons. All applicants will receive consideration for membership without regard to race, creed, religion, physical appearance, gender, color, sex, sexual orientation, gender identity/expression, national origin/ancestry, age, disability, marital status, political affiliation, disabled veteran status or other protected status. By clicking below I acknowledge this statement.
I hereby affirm that the information provided on this application (including any uploaded documents) is true and complete. I understand that any false or misleading representation or omissions may disqualify me from further consideration for membership and may result in discharge from membership if discovered at a later date. I understand that completion of this application does not assure me of a position with Dodge County Emergency Response Team Inc. By clicking below I acknowledge this statement.
I understand that this is an unpaid volunteer position, and that if selected, I will not be compensated.
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