Emergency Support Unit Application

Contact Information

Business name

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

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

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.