Orange County (NY) HAZMAT Response Team Membership Application

1. Orange County
Department of Emergency Services
Division of Division of Fire Services
Hazardous Materials Response Team
Volunteer Application Form
Instructions
1. Complete all applicable portions.
2. Attach copies of certificates of completion for:
• Hazmat Operations or Fire Fighter #1
• Hazmat Technician (if completed)
• Drivers License
• OSHA compliant physical (if completed)
• ICS courses IS-100 and IS 700
• Any others related to emergency services
3. Sign the application
4. Return the application and supporting documents to an active member or the Fire
Training Center front desk or by mail to;
Orange County Hazmat Team
9 Training Center Ave
Goshen N.Y. 10924
5. Respond as directed upon receipt of a letter from the Team

2. Orange County
Department of Emergency Services
Division of Division of Fire Services
Hazardous Materials Response Team
Volunteer Application Form
Contact Information
Name: __________________________________________________________
Home Address:____________________________________________________
City:_____________________ State:________________ Zip: _______________
Daytime Phone: Evening Phone:
Cell Phone: Email Address:
Other: __________________________ Other:______________________________
Emergency
Contact Number: Relationship:
Personal Information
Date of Birth:
Have you ever been convicted of a felony? Yes No If Yes, please explain in the
remarks section)
Present Employer :____________________________________________________
Address: ____________________________________________________________
___________________________________________________________________
Position Held: _______________________ Phone: __________________________

3. Orange County
Department of Emergency Services
Division of Division of Fire Services
Hazardous Materials Response Team
Volunteer Application Form
Skills
Please Check All Appropriate:
Are you a firefighter?: Yes No
If Yes, what Department?: ________________________________________
Are you an EMT or Paramedic?: Yes No
If Yes, what Corps or Service?_____________________________________
Are you a Police Officer?: Yes No
If Yes, what Department?: ________________________________________
Are you a trade professional associated with
hazardous materials? Yes No
If Yes, What Company? _________________________________________
Have you served on Active Duty in the Military?: Yes No
Branch: _____________ Years on Active Duty: ______________________
Highest Rank: ______ Occupational Specialty ______________________
Are you a current member of the National Guard or Reserve?: Yes No
Branch: _________ Rank: ____ Occupational Specialty________________
Have you completed Hazmat First Responder Operations? Yes No
If Yes, what year?: _____________________
Have you completed Hazmat Technician certification? Yes No
If Yes, date of last certification? _____________________
Have you been a member of another Hazmat Team? Yes No
If Yes, which one? _____________________

4. Orange County
Department of Emergency Services
Division of Division of Fire Services
Hazardous Materials Response Team
Volunteer Application Form
Skills (Cont.)
Have you received Incident Command System (ICS) training?: Yes No
If Yes, check all that apply:
ICS 100 ICS 200 ICS 300 ICS 400
IS 700 IS 800
Languages Spoken/Written: _____________________________________________
____________________________________________________________________
Professional Licenses: _________________________________________________
____________________________________________________________________
Drivers License Number: ___________________ State: ____________
Other skills that would be of use to the Team:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

5. Orange County
Department of Emergency Services
Division of Division of Fire Services
Hazardous Materials Response Team
Volunteer Application Form
Remarks
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Signature: ____________________________________________________________
If you have any questions, please contact the Division of Fire Services at (845)-374-1900.
Please Return Application Form to:
Orange County Deputy Fire Coordinator Hazmat
Division of Fire Services
Orange County Fire Training Center
9 Training Center Lane
Goshen, NY 10924
______________________ _________________
Team Leader Acceptance Date