EOC Credential Application

Attachment 4

Emergency Management Division 2014 Annual EOC Credential Application

Please ensure you are on the Authorized List submitted to EMD by your ESF Lead

Name: ______(Check one) New EOC Personnel Renewal EOC Position: (i.e. ESF 2 Supervisor, Supervisor)

______

Municipality/Department/Agency:

______

ESF #/Unit/ Section or Area of Assignment:

______

ESF Lead/Unit Supervisor:

______

Work Address:

______

Email Address: ______

Cell Phone: ______Work Phone: ______FAX: ______

(Check one) □ I do not have a Johnson Controls access card. □ I currently have a Johnson Controls access card and the number (back of card, top right corner) is: ______

I agree to adhere to the EOC Policies and Procedures posted in the Broward County on- line WebEOC File Library. EMD STAFF USE ONLY: Certificates Provided:

IS 100___ IS 200___ ICS 300___ ICS 400___ IS 700___ IS 701___ IS 702___ IS 703___ IS 704 N/A IS 706___ IS 800____

WebEOC (Classroom) ____ WebEOC (On-Line) _____

ID Approved____ ID Denied ____ Reason______

EMD Evaluator______Attachment 4

Name (Print) ______Signature ______

Date ______

Credentials will not be issued without the proper documentation. For additional information or to schedule an appointment, please contact Penni Weinstein-Long at 954-831- 3903 or [email protected] Credentials are processed and issued at the EOC: Emergency Management Division 201 NW 84th Avenue, Plantation, FL

Please contact Penni directly if you need a new ID

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EMD STAFF USE ONLY: Certificates Provided:

IS 100___ IS 200___ ICS 300___ ICS 400___ IS 700___ IS 701___ IS 702___ IS 703___ IS 704 N/A IS 706___ IS 800____

WebEOC (Classroom) ____ WebEOC (On-Line) _____

ID Approved____ ID Denied ____ Reason______

EMD Evaluator______