|
|
Seattle Auxiliary Communication Service
ACS
Application for Membership
Seattle ACS is the Emergency Communications
Teams that provides support to the City of Seattle. A program of the
Seattle Office of Emergency Management - a volunteer Amateur Radio
emergency worker group authorized through the Federal Government RACES and
the State of Washington.
Please complete the following information (due
to the sensitive and secure nature of City of Seattle emergency
information and facilities, all applicants will be required to undergo a
basic criminal records check.) |
|
| Check
One: |
New Application
Renewal
|
| Current ID
Badge # |
|
|
| Personal
Information: |
|
| Last Name |
|
| First Name |
|
| Middle Initial |
|
| Date |
|
| Amateur Radio Call
Sign |
|
| Occupation/Employer |
|
|
| Residence
Address: |
|
| Street |
|
| City |
|
| State |
|
| Zip Code |
|
|
| Mailing
Address: |
|
| Street |
|
| City |
|
| State |
|
| Zip Code |
|
| Home Phone |
|
| Work Phone |
|
| E-Mail Address |
|
| Pager |
|
| Service
Provider |
|
| Alphanumeric |
Yes
No |
|
| State Emergency
Worker Information: |
|
| Date of Birth |
|
| Height |
|
| Weight |
|
| Hair Color |
|
| Eye Color |
|
| Person to Contact in
Case of Emergency |
|
| Relationship |
|
| Emergency Contact Home
Phone |
|
| Emergency Contact Work
Phone |
|
|
| Comments or questions: |
|
|
| I
certify that I have read the Mission and
Purpose Statement for Seattle ACS as well as the Personal
Responsibilities of Emergency Workers section (118-04-200) of WAC
118-04 and hereby agree to comply with the requirements and I certify
that this is my true identity and acknowledge that the City may check
criminal records systems for any criminal history. Findings of criminal
records may or may not be grounds for disqualification from membership and
will be reviewed case-by-case.
|
|
|
|
Signature:
Date:
Please mail signed form to:
Seattle EOC
ACS/MST Application
2320 4th Avenue
Seattle, WA 98121-1718
Questions: contact Mark Sheppard at 206 233
5076 |