Lake and Mchenry Counties Fire Departments

MEMBERSHIP APPLICATION / UPDATE (Check all that apply)

 DIVE  SONAR  SWIFTWATER / FLOOD  TECH RESCUE  HAZ-MAT  MECHANICS  WILDLAND Date of Application:  APPLICATION TO TEAM(S)  UPDATED INFORMATION ONLY

Print or Type Name Last, First Name, MI

Fire Department:

Fire Dept. Street Mailing Address:

City State Zip

FD Phone:

FD Fax:

Cell Phone: #: Carrier Nextel Direct Connect #

Pager: #: Carrier

Email Address:

Indicate Date of Certification(s) and Certifying Agency

DIVE (List current classes / certifications)) Course Date Certifying Agency

Special Skills / other courses:

SONAR (List current classes / certifications)) Course Date Certifying Agency

SRT Application/Updated JUN-2012 1

SEND COMPLETED APPLICATIONS TO THE SRT OFFICE 866-560-5538 (FAX) Special Skills / other courses:

SWIFTWATER / FLOOD (List current classes / certifications) * Required Courses Course Date Certifying Agency *Swiftwater 1 *Swiftwater 2 Water Operations Water Craft Technician

TECHNICAL RESCUE (must be trained to the operations level in all four disciplines to apply) Course Date Certifying Agency Rope Ops Rope Tech Confined Space Ops Confined Space Tech Trench Ops Trench Tech Structural Collapse Ops Structural Collapse Tech

HAZARDOUS MATERIALS Course Date Certifying Agency Operations Tech-A Tech-B Other

MECHANICS Special Skills:

WILDLAND * Required Courses Course Date Course Date Course Date *S-130 Basic S-131 Advanced S-290 Inter. Firefighter Firefighter/Squad Wildland Fire Boss Behavior *S-190 Intro. S-215 Fire Ops in the *PASSED PACK To Wildland Wildland/Urban TEST Fire Behavior Interface *I-100 ICS S-230 Crew Boss- Other Orientation, Single Resource Module 1 *L-180 S-231 Engine Boss- Other Human Single Resource Factors on the Fireline Special Skills:

* AUTHORIZATION

[Office Use] Review Date:  APPROVED  NOT APPROVED by:______Interview Comments: Date:

Entered By: Date:

SRT Application/Updated JUN-2012 3

SEND COMPLETED APPLICATIONS TO THE SRT OFFICE 866-560-5538 (FAX)