KCOEM - Electronic Application for Membership

Application for Membership

The Kane County Office of Emergency Management does not discriminate on the basis of
age, race, color, sex, religion, national origin, handicap or veteran status as prohibited by law.

Personal Information

First Name:	Middle Name:	Last Name:		Maiden Name:
Address:

City:	State:	Zip Code:	-	County:
Home Telephone Number:		Work Telephone Number:
Cellular Telephone Number:		Pager Telephone Number:
Date Of Birth:		Amateur Call Sign:
Email Address:		Verify Email Address:
Do you have any illness, physical or mental disability which may hinder you in performing the duties as a volunteer member?
If yes, please explain:

Education

	School Name	School Location	Course of Study	Dates Attended	Degree / Certificate / Diploma
High School				through
College / University				through
College / University				through
Other				through

Military

Complete this section ONLY if you are currently serving or have served in the United States Armed Forces.

Armed Forces Branch:	Dates of Active Duty:	through
Date of Discharge:	Type of Discharge:
Describe your duties:
Describe any special training:

Armed Forces Branch:	Dates of Active Duty:	through
Date of Discharge:	Type of Discharge:
Describe your duties:
Describe any special training:

Skills

Employment History

Please provide accurate, complete, full-time and part-time employment history. Start with the present or most recent employer. Please include volunteer organizations and activities at the end.

Company Name:
Address:

City:
State:
Zip Code:	-
Telephone Number:
Name of Supervisor:
Title of Supervisor:
Dates Employed:	through
Job Title:
Duties:
Reason for Leaving:
Do you have any objections if we contact this employer:
If yes, please explain:

Company Name:
Address:

City:
State:
Zip Code:	-
Telephone Number:
Name of Supervisor:
Title of Supervisor:
Dates Employed:	through
Job Title:
Duties:
Reason for Leaving:
Do you have any objections if we contact this employer:
If yes, please explain:

Company Name:
Address:

City:
State:
Zip Code:	-
Telephone Number:
Name of Supervisor:
Title of Supervisor:
Dates Employed:	through
Job Title:
Duties:
Reason for Leaving:
Do you have any objections if we contact this employer:
If yes, please explain:

Company Name:
Address:

City:
State:
Zip Code:	-
Telephone Number:
Name of Supervisor:
Title of Supervisor:
Dates Employed:	through
Job Title:
Duties:
Reason for Leaving:
Do you have any objections if we contact this employer:
If yes, please explain:

Memberships / Professional Organizations

References

Name	Address	Relationship	Telephone Number	Years Known

Comments

I understand that acceptance for this application does not signify immediate membership in the Kane County Office if Emergency Management. I further understand that in consideration of this application I may be required to submit a fingerprint-based criminal history search to positively confirm my identity.

To that end I authorize the release of all personal and criminal history information to the Kane County Office of Emergency Management. I declare that the information provided by me in this Application for Membership is true, correct and complete to the best of my knowledge.

If this Application for Membership is accepted I agree to conform to all rules, regulations, directives and policies which the County of Kane my periodically promulgate, withdrawal or modify. I understand that my membership my be terminated with or without cause and with or without notice, at the option of either the agency Director or myself.

I further understand that if accepted, any misstatement or omission on this application shall be considered cause for dismissal.

Signature: Date:

Kane County OEM

777 E. Fabyan Parkway

Geneva, IL 60134