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Waupaca Co HazMat Team

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Application For Membership

REQUIREMENTS FOR  MEMBERSHIP

All members will participate in scheduled drills and exercises throughout the training year.  Training activities will be sufficient to support and achieve at least the minimum federally mandated standards (NFPA 472) and provide for self-confidence.

  1. Be an active member of a fire department, ambulance agency, municipality, or private sector business in Waupaca County.
  2. Medical and Technical requirements:
    1. Be certified medically fit to perform HazMat Technician, EMS or other support functions as attested to by applicant's Fire/EMS department physician or personal physician.
    2. Members of business/private sector who provide technical support will require medical certification
    3. Participate in annual fit testing for any required mask and respiratory protective equipment
    4. Members will submit an Employment Application with Waupaca County Human Resources Dept.
    5. Training Competency
      1. HazMat Technician: must have completed HazMat Technician-Basic, and able to perform all required NFPA 472 competencies
      2. Support members (Operations):  must have completed HazMat Operations and will maintain qualification and skills relevant to their specialty or function as attested to by credentialing, business industry standards or independent evaluation.  Must be able to perform all required NFPA 472 competencies for HazMat Operations
      3. Members must achieve and maintain these requirements annually to remain an active member with the Waupaca County  HazMat Team or participate in HazMat response.

An application form sometimes makes it difficult for an individual to adequately summarize a complete background.  Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying. (use extra paper in needed)

APPLICANT  INFORMATION

Name:
Address:
City or Town:
State or Province:
Phone:
Cell:
Email:


FIRE/EMS SERVICE INFORMATION (if applicable)
Name of Current Affiliation:
Chiefs/Directors Name: 
Phone:
Address: 
City/Town:
ZipCode
Date Joined
Current Rank/Position: 


Training: (Please þthe training programs that you have completed)
HazMat Awareness      HAZMAT Operations      HAZMAT Technician      HAZMAT Specialist 
Incident Command System (ICS) training:  ICS-100      ICS-200     ICS-300      ICS-400      ICS-700 

Date of last HazMat Technician Annual Refresher: 
Provider:
   

Other Training: (EG: Fire Fighting Classes, EMT, CRF, Etc.)


(1000 characters maximum)
Upload Training Certificates (please provide copies of certificates with application form)  
   

Briefly state why you want to be a member of the Waupaca County HazMat Team and how you became aware of the team.  (2000 characters maximum)

I have read and understand the requirements for membership and agree to them.  I certify that the information on this application for is true and correct to the best of my knowledge.  (must be checked)

 
     







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