South Carolina Fire Academy

Size: px
Start display at page:

Download "South Carolina Fire Academy"

Transcription

1 South Carolina Fire Academy Presents the South Carolina / Rhode Island State Weekend at the National Fire Academy July 10-12, 2015 Emmitsburg, Maryland STATE OF SOUTH CAROLINA OFFICE OF STATE FIRE MARSHAL DIVISION OF FIRE AND LIFE SAFETY S TAT E F I R E South Carolina Fire Academy A Center of Excellence

2 2015 State Weekend Course Offerings South Carolina Offerings: W Executive Skills Series: Exercising Leadership Within Communities The purpose of this course is to provide Fire Service authority figures with knowledge and skills, enabling them to exercise leadership when confronting adaptive challenges presented by increasingly diverse internal and external communities. The goal of the course is for participants to utilize the diversity of ideas, peoples and cultures as resources in exercising leadership to address adaptive challenges in their communities Target Audience: Fire and emergency service personnel in positions of authority. W Incident Safety Officer (Revised) This 2-day course examines the Safety Officer s role at emergency responses. A specific focus on operations within an Incident Command System (ICS) as a Safety Officer is a main theme. Response to all-hazards types of situations will be emphasized. Target Audience: Individuals who have a Safety Officer responsibility at emergency operation situations. Persons attending this course should have a working knowledge of the ICS, as taught by NFA, building construction principles, hazardous materials management, applicable NFPA guidelines, and Federal regulations. W New Fire Chief I: Challenging Issues This course is designed to develop the managerial, administrative and leadership skills necessary for the fire time fire chief and chief officer who desire a leadership position in their department. This course addresses critical knowledge and skills pertaining to the responsibilities of a fire chief including such topics as local politics and the role of the chief officer, liability and risk management, resources and items of knowledge need to become a first time leader in a new position in their agency. Target Audience: The primary candidates for this course include new or emerging chief officers in a volunteer or combination fire department or emergency service organization. The secondary candidate is a person who is a new career chief, department leader or emerging leader of fire department or emergency service organization. This course is open to all interested emergency services personnel including volunteer, career, and allied professionals, the class is intended primarily for those who have served or will begin to serve soon in leadership positions and who seek to learn more effective ways of managing and leading their agency. W Community Risk Issues and Prevention Interventions This 2-day course is designed for students who work in the field of prevention. Students learn a basic overview of the three E s of prevention--education, engineering, and enforcement. The course concludes that the most effective way to combat community risk issues is to develop strategies that use all three E s. The course is designed to provide the motivation and leadership for local organizations to enhance their prevention efforts. Course content includes* evaluation of the types and levels of community prevention;* how injuries, fires, and burns can be prevented;* strategies and countermeasures to help people understand the injury, fire, or burn event and reduce the loss; and* prevention approaches--behavior changes, legislation, and enforcement and engineering.

3 2015 State Weekend Course Offerings Target Audience: * Prevention personnel in local organizations.* Persons serving on local or State prevention committees.* Fire marshals, inspectors, and public educators.* Career and volunteer firefighters who have prevention responsibilities.* EMS personnel who coordinate community life-support programs.* Community volunteers wishing to enhance fire and life safety efforts.* Community health educators.* Part-time or full-time public educators. W Preparation for Initial Company Operations This course is designed to develop a better understanding of the role and responsibilities of a Company Officer in preparing their company for incident operations. In addition, to clarify the transition from firefighter to company officer and the new roles relating to leadership and safety. This course is designed for company officers, acting company officers, or senior firefighters responsible for the management of a single fire company at an emergency incident. Those officers who are responsible for company readiness, personnel safety, and leadership as it relates to company operation. Target Audience: Company officers, acting officers, or senior firefighters who command a fire company during emergency operations. Those officers who are responsible for maintaining skills and company readiness. STATE OF SOUTH CAROLINA Rhode Island Offerings: W Fire Service Safety Culture: Who Protects Firefighters from Firefighters? This is a 2-day course that will help fire service personnel identify their present fire service safety culture, explain how culture drives safety behavior, identify risk management strategies, and develop a fire service safety culture intervention plan to reduce injury and death to firefighters in their organization. The course content includes National Institute of Occupation Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program reports, organizational change and leadership models, and risk control systems. The learning methods include case studies, problem solving, and strategic and tactical planning that are used in individual, small group, and class activities. OFFICE OF STATE FIRE MARSHAL DIVISION OF FIRE AND LIFE SAFETY S TAT E F I R E Target Audience: Key fire service personnel in the position of leadership and the Company Officers (COs) who are the agents of change within all types and sizes of fire departments. Attendees should possess effective oral and written communication skills with some experience in public speaking.. W Incident Command System and Resource Management for the Fire Service This is a significantly revised 2-day program providing students with an understanding of the Incident Command System (ICS) and Resource Management for the Fire Service and their application in both emergency and nonemergency situations. This course addresses the need for an ICS, an overview of the structure and flexibility of ICS, and an understanding of the command skills necessary to function effectively in an ICS structure and the need to effectively manage your resources. This course meets the requirements of ICS 100 & ICS 200 Target Audience: All first responders with responsibilities to use, deploy, implement, and/or function within an ICS and Resource Management.

4 2015 State Weekend Course Offerings W Decision Making for Initial Company Operations This course is designed to develop the decision making skills needed by Company Officers (COs) to accomplish assigned tactics at structure fires. All activities and scenarios used in this course are based on structure fires. As a Company Officer (CO), with the real possibility of being the first to arrive at an incident, the COs initial decisions will have an impact throughout the entire incident. It is vital they be able to make good management decisions that have a favorable impact on the eventual outcome. In addition to a possible role as the initial Incident Commander (IC), the CO may well be assigned a subordinate position within the ICS organization. COs need to have a clear understanding of the system, the assigned position, and their role in the organization if they are to function effectively and help make the system work. Target Audience: This course is specifically designed for newly appointed Company Officers, for firefighters who may have acting Company Officer responsibilities or who want to become a Company Officer. This course is an excellent review for experienced Company Officers. W Executive Skill Series: Exercising Leadership Ethically (ESS:ELE) This new two-day ESS:ELE course provides students with the ability to recognize ethical dilemmas in the context of their environments, apply a decision model to resolve these dilemmas, render ethical decisions, and defend under scrutiny the resulting decisions that were made in an effort to resolve these dilemmas. The ESS: ELE course will become the fourth offering within the Executive Skill Series. Target Audience: This course (along with all of the Executive Skill Series courses including the Exercising Leadership Ethically course), is designed for fire and emergency services personnel in positions of authority who have an opportunity to exercise leadership. An eligible student must be minimally assigned in a supervisory level position (e.g., a Company Officer). Please note, line-firefighters or firefighter-paramedics are not within the target audience and will not be considered. W Leadership II for Fire and EMS: Strategies for Personal Success This two-day course provides the Company Officer with the basic leadership skills and tools needed to perform effectively in the fire service environment. The course addresses ethics, use and abuse of power at the company officer level, creativity in the fire service environment, and management of the multiple roles of the company officer. Target Audience: In the lower-division baccalaureate/associate degree category, one semester hour in fire service administration, fire tech, fire management, fire science, emergency management, public administration, human resource management, or leadership.

5 Registration Deadline to submit registrations to the South Carolina Fire Academy is May 20, Student SID Number: A FEMA SID is required to register for and participate in any training provided by FEMA agencies. FEMA training providers registration systems and enrollment procedures require a valid FEMA SID. FEMA SID serves as your personal identification number and merges/links/connects/combines all of your FEMA training records under one account to simplify keeping track of your FEMA training accomplishments. You may obtain a SID number at the following web address: Programs are open to all applicants. Early registration is recommended as enrollment in each program is limited to 30 students, unless otherwise noted. Applicants must list three course choices. Weekend Cost: $80. This includes Friday night dinner, three meals Saturday (cookout/social), breakfast and lunch Sunday. How to Apply: Students must complete the NFA Student Registration form included with this brochure. For convenience, students may submit the form via , fax or mail. Completed forms must be submitted to: STATE OF SOUTH CAROLINA South Carolina Fire Academy 141 Monticello Trail Columbia, S.C FAX: (803) emory.johnson@llr.sc.gov OFFICE OF STATE FIRE MARSHAL DIVISION OF FIRE AND LIFE SAFETY Confirmations: Shortly after June 2, 2015, confirmations will be mailed. If the first course a student registered for is canceled or full, the student will be transferred to one of the other choices. S TAT E F I R E National Fire Academy Policy: A student who fails to attend class and did not cancel his/her enrollment will be suspended from attending NFA courses for a period of two years. Itinerary of Events Friday, July 10, 2015 (7 p.m.): Orientation, Building J auditorium. Immediately after orientation, a social will be held in the Command Post Pub. This is an opportunity to relax and socialize with other students. Classes will be held in Building J. -Saturday classes are 8 a.m. to 5 p.m. -Sunday classes are 8 a.m. to 3 p.m. Saturday, July 11, 2015 (5:15 p.m.): Memorial Service to honor fallen firefighters from each state, a brief joint memorial service will be held in the campus chapel. After the memorial service, a cookout will be held at the Log Cabin. This is an opportunity for attendees to join together in fellowship.

6 Travel Arrangements Students must make their own travel arrangements. From S.C., the drive is typically eight to 10 hours. Transportation costs are the responsibility of the student or his/her organization and will not be reimbursed by the National Fire Academy or the S.C. Fire Academy. Please arrive Friday, July 10, 2015 no later than 6 p.m. to check into the dormitory and attend the 7 p.m. orientation session. Air travel can be arranged to either Washington National Airport or Baltimore-Washington International Airport. If flying, students are responsible for providing their own ground transportation to NFA. Driving Directions to the National Fire Academy Via Interstate N to I-395 I-395 N to I-495 N I-495 N to I-270 N I-270 N becomes US-40 W US-40 W becomes US-15 N US-15 N through Thurmont to South Seton Avenue Turn left onto South Seton Avenue (MD-140) Turn right into NETC/NFA campus Via Interstate 77 I-77 N to I-81 near Wytheville VA I-81 N to PA-16 toward Waynesboro PA PA-16 becomes MD-140 Turn right at traffic light ontosouth Seton Avenue Turn left into NETC/NFA campus Please contact: Emory Johnson State Weekend Coordinator (803) emory.johnson@llr.sc.gov

7 S.C. State Weekend Application DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY GENERAL ADMISSIONS APPLICATION SHORT FORM See Reverse for Privacy Act Statement O.M.B. No Expires November 30, 2016 SECTION I - GENERAL INFORMATION 1. DATE OF BIRTH (Mo, Day, Yr.) 2. GENDER 3. U.S. CITIZEN If No, City and Country of Birth: FEMALE MALE YES NO PERMANENT RESIDENT 4. RACE (Please check all that apply) 1. AMERICAN INDIAN or ALASKAN NATIVE 2. ASIAN 3. BLACK or AFRICAN AMERICAN 4a. ETHNICITY HISPANIC or LATINO 4. WHITE 5. NATIVE HAWAIIAN or PACIFIC ISLANDER 5. PLEASE PRINT YOUR NAME (Last, First, Middle, Suffix) NOT HISPANIC or LATINO 6. STUDENT IDENTIFICATION (SID) NUMBER 7. HOME MAILING ADDRESS (Street, avenue, road no., P.O. box/city or town, and zip code) 8. WORK PHONE Number ( ) 9. HOME PHONE Number ( ) 10. FAX Number ( ) 12a. ENTER COURSE CODE AND TITLE 11. ADDRESS 12b. COURSE LOCATION 12c. DATE Emmitsburg July 12-13, DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING YOUR ATTENDANCE IN TRAINING? NO YES (If yes, indicate & describe any special considerations required on a separate sheet) SECTION II - EMPLOYMENT INFORMATION 14a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED 14b. NFIRS # 15. CURRENT POSITION AND NUMBER OF YEARS IN (NFA ONLY) POSITION 16. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION 16b. ORGANIZATION 16c. CURRENT STATUS 16a. JURISDICTION 1. PAID FULL TIME. 1. STATEWIDE 4. SPECIAL DISTRICT/TOWNSHIP 7. FOREIGN 1. ALL CAREER 2. PAID PART TIME 2. COUNTY GOVERNMENT 5. FEDERAL/MILITARY (non-dhs) 8. DHS/FEMA 2. ALL VOLUNTEER 3. VOLUNTEER 3. CITY/TOWN/VILLAGE 6. INDUSTRY/BUSINESS 9. TRIBAL NATION 3. COMBINATION 4. DISASTER RESERVIST SECTION III - ENDORSEMENT AND CERTIFICATION 17a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (U.S.C. 1001). 17b. I hereby authorize the release of any and all information concerning my enrollment in this course to the chief officer in charge, or designee, of my organization. All requests for information shall be in writing from said chief officer or designee. 17c. Further, I understand that the National Emergency Training Center (NETC), the Mt. Weather Emergency Operations Center (MWEOC), and the Noble Training Facility (NTF) are not authorized to provide medical or health insurance for students. I maintain appropriate insurance on an individual basis. 17d. I agree to abide by the rules, policies, and regulations of NETC, MWEOC and NTF. Failure to do so will result in denial of the student stipend, expulsion from the course, and possible barring from future National Fire Academy (NFA) and Emergency Management Institute (EMI) courses. 18a. SIGNATURE OF APPLICANT 18b. DATE 19. APPROVAL BY THE HEAD OF THE SPONSORING ORGANIZATION (NOT REQUIRED FOR SELF STUDY PROGRAMS) By signing this application, I certify that my organization does not discriminate on the basis of age, gender, race, color, religious belief, national origin, economic status, or disability in providing educational opportunities for its employees. 19a. SIGNATURE 19b. PRINTED NAME AND TITLE 19c. DATE 20. ADDITIONAL ENDORSEMENTS FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE (NOT REQUIRED FOR SELF STUDY PROGRAMS) 20a. SIGNATURE AND DATE (State Office) 20b. SIGNATURE AND DATE (FEMA Regional Office) 21. SUBMIT APPLICATION TO APPROPRIATE SPONSOR FEMA Form , (2/12) Complete form and list three choices in order of preference. Second and third choice may be listed to the right. Return form with $80 payment to: PREVIOUS EDITION FF75-5A OBSOLETE Second Choice Third Choice South Carolina Fire Academy 141 Monticello Trail Columbia, SC 29212

8 South Carolina Department of Labor, Licensing and Regulation South Carolina Fire Academy 141 Monticello Trail Columbia, South Carolina 29203

FLORIDA STATE WEEKEND April 28 through 30, 2017

FLORIDA STATE WEEKEND April 28 through 30, 2017 WELCOME TO THE ANNUAL FLORIDA STATE WEEKEND AT THE NATIONAL FIRE ACADEMY IN EMMITSBURG, MARYLAND We hope you will have the opportunity to join us this year! The education you receive from experienced instructors,

More information

FLORIDA STATE WEEKEND May 13 through 15, 2016

FLORIDA STATE WEEKEND May 13 through 15, 2016 WELCOME TO THE ANNUAL FLORIDA STATE WEEKEND AT THE NATIONAL FIRE ACADEMY IN EMMITSBURG, MARYLAND We hope you will have the opportunity to join us this year! The education you receive from experienced instructors,

More information

South Carolina Fire Academy

South Carolina Fire Academy South Carolina Fire Academy Presents the South Carolina / Rhode Island State Weekend at the National Fire Academy July 13-15, 2018 Emmitsburg, Maryland South Carolina Fire Academy A Center of Excellence

More information

South Carolina Fire Academy

South Carolina Fire Academy South Carolina Fire Academy Presents the South Carolina / Rhode Island State Weekend At the National Fire Academy July 22-24, 2016 Emmitsburg, Maryland South Carolina Fire Academy A Center of Excellence

More information

Rhode Island Fire Instructors Association National Fire Academy Weekend

Rhode Island Fire Instructors Association National Fire Academy Weekend Rhode Island Fire Instructors Association National Fire Academy Weekend July 12 July 13, 2014 Rhode Island South Carolina The Rhode Island-South Carolina State Weekend offers firefighters the opportunity

More information

JUNE 9-10, 2018 NEW JERSEY WEEKEND AT THE NATIONAL FIRE ACADEMY

JUNE 9-10, 2018 NEW JERSEY WEEKEND AT THE NATIONAL FIRE ACADEMY NEW JERSEY WEEKEND AT THE NATIONAL FIRE ACADEMY JUNE 9-10, 2018 Presented by: New Jersey Department of Community Affairs & New Jersey Division of Fire Safety Program Overview & Registration The New Jersey

More information

National Fire Academy Emmitsburg, MD. Sponsored in part through the generosity of Globe Manufacturing Company, LLC

National Fire Academy Emmitsburg, MD. Sponsored in part through the generosity of Globe Manufacturing Company, LLC National Fire Academy Emmitsburg, MD Sponsored in part through the generosity of Globe Manufacturing Company, LLC Vermont Fire Academy s 2015 NFA 3-State Weekend Application Checklist Review the seven

More information

NYS Weekend C/o Fire Academy FSA 600 College Ave. Montour Falls, NY 14865

NYS Weekend C/o Fire Academy FSA 600 College Ave. Montour Falls, NY 14865 TWENTY-EIGHT ANNUAL NEW YORK STATE WEEKEND NATIONAL FIRE ACADEMY EMMITSBURG, MARYLAND March 9-10, 2013 The New York State Office of Fire Prevention and Control and the Fire Academy Faculty Student Association

More information

TWENTY-Fourth ANNUAL NEW YORK STATE WEEKEND NATIONAL FIRE ACADEMY EMMITSBURG, MARYLAND

TWENTY-Fourth ANNUAL NEW YORK STATE WEEKEND NATIONAL FIRE ACADEMY EMMITSBURG, MARYLAND TWENTY-Fourth ANNUAL NEW YORK STATE WEEKEND NATIONAL FIRE ACADEMY EMMITSBURG, MARYLAND March 6 8, 2009 Arrangements for the New York State Weekend are being made by the New York State Office of Fire Prevention

More information

W FIRE INVESTIGATION: FIRST RESPONDERS

W FIRE INVESTIGATION: FIRST RESPONDERS 2017 MD WEEKEND @ NFA.indd 3 11/8/17 11:07 AM W0379 - FIRE INVESTIGATION: FIRST RESPONDERS This course is designed specifically to provide a clear definition of the role of first responders in fire investigation

More information

Last Name First Name M.I. Name You Prefer. City State Zip Address. Daytime Phone Evening Phone Best Time to Call. City State If yes, where?

Last Name First Name M.I. Name You Prefer. City State Zip  Address. Daytime Phone Evening Phone Best Time to Call. City State If yes, where? GENERAL INFORMATION Last Name First Name M.I. Name You Prefer Mailing Address How long at this address? City State Zip County If less than a year, previous address How long have you resided in the county?

More information

FIRE RECRUIT CIVIL SERVICE COMMISSION CITY OF TYLER, TEXAS MINIMUM QUALIFICATIONS

FIRE RECRUIT CIVIL SERVICE COMMISSION CITY OF TYLER, TEXAS MINIMUM QUALIFICATIONS >0?.\. CIVIL SERVICE COMMISSION CITY OF TYLER, TEXAS Announces an Examination for FIRE RECRUIT ANNOUNCEMENT OPENS: THURSDAY, JULY 19, 2018 AT 9:30 A.M. APPLICATION DEADLINE: FRIDAY, AUGUST l7, 2018 AT

More information

CPRS Application. Certified Peer Recovery Specialist. VCB CPRS Application Revised February

CPRS Application. Certified Peer Recovery Specialist. VCB CPRS Application Revised February CPRS Application Certified Peer Recovery Specialist VCB CPRS Application Revised February 2017 - www.vacertboard.org - info@vacertboard.org 1 DIRECTIONS/CHECKLIST Documentation of high school diploma/ged

More information

EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION Travis County Human Resources Management Department 1010 Lavaca Street, 2 nd Floor (corner of West 11th & Lavaca) www.co.travis.tx.us P.O. Box 1748 Austin, TX 78767 (512) 854-9165 Voice EMPLOYMENT APPLICATION

More information

Young, Beginning, Small and Minority Farmer elearning Course Ag Biz Planner

Young, Beginning, Small and Minority Farmer elearning Course Ag Biz Planner Young, Beginning, Small and Minority Farmer elearning Course Ag Biz Planner Ag Biz Planner Program Goals: Assist young, beginning, small and minority farmers in becoming more successful business people

More information

CDL APPLICATION FOR EMPLOYMENT All applicants who have a CDL must complete this application.

CDL APPLICATION FOR EMPLOYMENT All applicants who have a CDL must complete this application. PO BOX 535 BROOKLYN, IA 52211-0535 PHONE: 641-522-9206 FAX: 641-522-5090 CDL APPLICATION FOR EMPLOYMENT All applicants who have a CDL must complete this application. NOTE TO THE APPLICANT: This application

More information

MESA Summer Academy: Solar System Mission Possible Application Deadline: June 1, 2018 Early Bird Discount Deadline: May 1, 2018

MESA Summer Academy: Solar System Mission Possible Application Deadline: June 1, 2018 Early Bird Discount Deadline: May 1, 2018 MESA Summer Academy: Solar System Mission Possible Application Deadline: June 1, 2018 Early Bird Discount Deadline: May 1, 2018 Program Description Get a head start on your career in space exploration

More information

Crandall Fire Department

Crandall Fire Department Crandall Fire Department Membership Application Today s Date Please Print or Type all information. All printing must be in BLUE ink. Omissions and/or false information are cause for rejection or dismissal.

More information

AVI Systems, Inc. Employment Application

AVI Systems, Inc. Employment Application Employment Application 952-949-3700 9675 West 76th Street, Suite 200 Eden Prairie, MN 55344 www.avisystems.com Applicant Information Date: Last First M.I. Street Address Apt/Unit # City State ZIP Code

More information

Columbia College Director of Teacher Education and Accreditation

Columbia College Director of Teacher Education and Accreditation Columbia College Director of Teacher Education and Accreditation Position Summary: Assists in the management of activities related to student progress through the teacher education programs, accreditation

More information

APPLICATION

APPLICATION MAYOR THOMAS C. HENRY CITY OF FORT WAYNE MAYOR S YOUTH ENGAGEMENT COUNCIL 2017-2018 APPLICATION Please mail, deliver or fax completed applications to: MAYOR S OFFICE, ATTN: KAREN L. RICHARDS 200 E. BERRY

More information

DELTA STATE UNIVERSITY ROBERT E. SMITH SCHOOL OF NURSING RN TO BSN COMPLETION PROGRAM APPLICATION

DELTA STATE UNIVERSITY ROBERT E. SMITH SCHOOL OF NURSING RN TO BSN COMPLETION PROGRAM APPLICATION RN TO BSN COMPLETION PROGRAM APPLICATION I am applying for the Fall of 20 Full-time Part-time 1. Name in Full (Last) (First) (Middle) 2. Home Address (Number & Street or RFD) (City) (State) (Zip) (County)

More information

Courses Being Offered:

Courses Being Offered: COLORADO STATE WINTER FIRE SCHOOL & NATIONAL FIRE ACADEMY WEEKEND January 30-31, 2016 COTC: Leadership January 30- February 2, 2016 FOII: February 1-5, 2016 All Courses Run 8am - 5pm WHERE: DoubleTree

More information

CITY OF HOLLY HILL EMPLOYMENT APPLICATION 1065 Ridgewood Avenue Holly Hill, Florida An Equal Opportunity Employer

CITY OF HOLLY HILL EMPLOYMENT APPLICATION 1065 Ridgewood Avenue Holly Hill, Florida An Equal Opportunity Employer The application must be filled out completely and accurately. PLEASE PRINT CAREFULLY or type all information. All materials submitted become the property of the City of Holly Hill and the information included

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT TICE TO APPLICANTS AND EMPLOYEES Screening tests for alcohol and illegal drug use may be required before hiring and during your employment here. APPLICATION FOR EMPLOYMENT We consider applications for

More information

EQUAL EMPLOYMENT OPPORTUNITY DATA FORM Please Return to: City of Geneva Human Resources 22 South First Street Geneva, IL 60134

EQUAL EMPLOYMENT OPPORTUNITY DATA FORM Please Return to: City of Geneva Human Resources 22 South First Street Geneva, IL 60134 EQUAL EMPLOYMENT OPPORTUNITY DATA FORM Please Return to: City of Geneva Human Resources 22 South First Street Geneva, IL 60134 The following information will be used to determine the effectiveness of the

More information

St. Mary s County Health Department

St. Mary s County Health Department St. Mary s County Health Department Meenakshi G. Brewster, M.D., M.P.H Health Officer Administration & Vital Records 301-475-4330 Community Health Services 301-475-4330 Resource Coordination 301-475-4389

More information

RHODE ISLAND DEPARTMENT OF PUBLIC SAFETY

RHODE ISLAND DEPARTMENT OF PUBLIC SAFETY RHODE ISLAND DEPARTMENT OF PUBLIC SAFETY S t a t e F i r e M a r s h a l 1951 Smith St, North Providence RI 02911 Telephone: (401) 383-7717 Fax: (401) 415-8608 Colonel Steven G. O Donnell Commissioner,

More information

Delta Phi Chi Military Sorority, Inc.

Delta Phi Chi Military Sorority, Inc. Delta Phi Chi Military Sorority, Inc. 2018 Application Checklist COMPLETED APPLICATION (5 Pages) PHOTO ID-Front & Back (Ensure PII is concealed) DD 214-Discharged Applicants (Ensure PII is concealed) Military

More information

Volunteer Application Package

Volunteer Application Package Volunteer Application Package April, 2016 This program is supported by the Georgia Department of Human Services/Division of Aging Services/GeorgiaCares Program with financial assistance, in whole or in

More information

CODAC BEHAVIORAL HEALTH SERVICES, INC.

CODAC BEHAVIORAL HEALTH SERVICES, INC. CODAC BEHAVIORAL HEALTH SERVICES, INC. Human Resources 1650 East Ft. Lowell Rd. Suite 202 Tucson, Arizona 85719 Administration: 520 327 4505 Human Resources: 520 202 1890 Fax: 520 202 1718 Website: www.codac.org

More information

Guidelines for Volunteer Chaplains

Guidelines for Volunteer Chaplains Guidelines for Volunteer Chaplains MedStar St. Mary's Hospital believes that care involves the social, emotional, spiritual, as well as the physical and chemical restoration of the person. Every person

More information

Leadership Commitment to Project GO goals Diversity For more information about Project GO, please visit

Leadership Commitment to Project GO goals Diversity For more information about Project GO, please visit PROJECT GO COMMON APPLICATION Project GO, an initiative of the Defense Language and National Security Education Office and administered by the Institute of International Education (IIE), provides fully

More information

AMERICAN AMBULANCE SERVICE, INC.

AMERICAN AMBULANCE SERVICE, INC. AMERICAN AMBULANCE SERVICE, INC. Proud to be a tobacco and smoke-free environment ONE AMERICAN WAY, NORWICH, CT 06360 VOLUNTEER APPLICATION GENERAL INFORMATION Date Name Last First MI Address Street City

More information

International Academy of Mathematics & Science

International Academy of Mathematics & Science International Academy of Mathematics & Science Fort Hays State University Hays, Kansas USA Founded in 1902, Fort Hays State University (FHSU) is a liberal arts, state-assisted institution in western Kansas

More information

DELTA SIGMA THETA SORORITY, INC. CINCINNATI ALUMNAE CHAPTER SCHOLASTIC ACHIEVEMENT AWARD (TYPE or PRINT ALL Information with a Black Ballpoint Pen)

DELTA SIGMA THETA SORORITY, INC. CINCINNATI ALUMNAE CHAPTER SCHOLASTIC ACHIEVEMENT AWARD (TYPE or PRINT ALL Information with a Black Ballpoint Pen) DELTA SIGMA THETA SORORITY, INC. CINCINNATI ALUMNAE CHAPTER SCHOLASTIC ACHIEVEMENT AWARD (TYPE or PRINT ALL Information with a Black Ballpoint Pen) 1 I. PERSONAL DATA Name: Last First Middle Number Street

More information

Application for Graduate Admission

Application for Graduate Admission Application for Graduate Admission D i v i s i o n o f m a n a g e m e n t M B A P R O G R a m Application MBA PROGRAM Instructions for Completion An MBA candidate may take as many as two courses (six

More information

STERILIZATION CONSENT FORM INSTRUCTIONS

STERILIZATION CONSENT FORM INSTRUCTIONS STERILIZATION CONSENT FORM INSTRUCTIONS In accordance with Title 42 Code of Federal Regulations (CFR) 50, Subpart B, all sterilizations require a valid consent form. The consent form can be downloaded

More information

Name: First Middle Initial Last Social Security Number: Current Street Address/Apt #: City: State: Zip Code:

Name: First Middle Initial Last Social Security Number: Current Street Address/Apt #: City: State: Zip Code: EASTERN SHIPBUILDING GROUP PO Box 960, Panama City, FL 32401 Phone: (850) 522-7413 Fax: (850) 874-0208 APPLICATION FOR AT-WILL EMPLOYMENT THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT but merely is intended

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT 270 Main Street PO Box 250 Southbridge, MA 01550 508-764-4329 saversbank.com APPLICATION FOR EMPLOYMENT Date of Application: Position Applied For: Name: Address: Number Street City State Zip Telephone:

More information

North Carolina A&T State University Undergraduate Admissions Application Instructions

North Carolina A&T State University Undergraduate Admissions Application Instructions 1 North Carolina A&T State University Undergraduate Admissions Application Instructions Thank you for your interest in North Carolina A&T State University! Please complete the admissions application carefully,

More information

PO BOX 535 BROOKLYN IA PHONE: FAX: APPLICATION FOR EMPLOYMENT PLEASE PRINT

PO BOX 535 BROOKLYN IA PHONE: FAX: APPLICATION FOR EMPLOYMENT PLEASE PRINT PO BOX 535 BROOKLYN IA 52211 PHONE: 641-522-9206 FAX: 641-522-5090 APPLICATION FOR EMPLOYMENT PLEASE PRINT NOTE TO THE APPLICANT: This application is used to evaluate your qualifications for employment.

More information

The completed application form and two recommendations must be postmarked or delivered by the application deadline, February 26, 2016.

The completed application form and two recommendations must be postmarked or delivered by the application deadline, February 26, 2016. Discovery Corps is a program that puts high school aged youth on the front lines of Pacific Science Center s mission to inspire lifelong interest in science. Motivated youth will delve into Pacific Science

More information

OPPORTUNITY GRANT APPLICATION

OPPORTUNITY GRANT APPLICATION OPPORTUNITY GRANT APPLICATION Name CBC SID# APPLICATION COMPLETION CHECKLIST Initial each line and return this checklist with your completed Opportunity Grant application. Review Opportunity Grant eligibility

More information

South Carolina Department of Social Services Emergency Shelters Program (ESP) APPLICATION FOR PARTICIPATION

South Carolina Department of Social Services Emergency Shelters Program (ESP) APPLICATION FOR PARTICIPATION South Carolina Department of Social Services Emergency Shelters Program (ESP) APPLICATION FOR PARTICIPATION Agreement Number: Federal Identification Number: Name and Address of Organization 1. Name: Telephone:

More information

North Carolina Extension Master Gardener Volunteer Application Guilford County

North Carolina Extension Master Gardener Volunteer Application Guilford County North Carolina Extension Master Gardener Volunteer Application Guilford County Please return all seven (7) pages of the completed Application to: 3309 Burlington Rd, Greensboro, NC 27405 GENERAL INFORMATION

More information

Dallas County Master Wellness Volunteer Program

Dallas County Master Wellness Volunteer Program Dallas County Master Wellness Volunteer Program The Master Wellness Volunteer Program is an educational campaign with the Texas AgriLife Extension Service (AgriLife Extension) focused on helping Dallas

More information

Work-Study Internship Application

Work-Study Internship Application Work-Study Internship Application 1 Centre Street, Room 2435, New York, NY 10007 212-386-0057 212-669-3633 (fax) psc@dcas.nyc.gov nyc.gov/psc Department of Citywide Administrative Services Lisette Camilo

More information

Employment is contingent upon completing a six (6) month probationary period.

Employment is contingent upon completing a six (6) month probationary period. Date All information on this application should be printed or typed. Complete or answer all questions. Incomplete applications may not be considered. Return completed application to: Chesapeake Bay Bridge

More information

INFORMATION CERTIFICATION

INFORMATION CERTIFICATION INFORMATION CERTIFICATION This form is required for employment. Please print or type and ensure all information is provided as omissions can delay processing. After acceptance of employment, applicants

More information

Candidates failing to include ALL required documentation will be disqualified.

Candidates failing to include ALL required documentation will be disqualified. To All Police Officer Candidates: Thank you for your interest in employment with the City of South St. Paul! We anticipate hiring two officers immediately with additional opening(s) occurring during the

More information

Scientific Research Disaster Recovery Grant (Cycle 1) Contact Information

Scientific Research Disaster Recovery Grant (Cycle 1) Contact Information Scientific Research Disaster Recovery Grant (Cycle 1) Contact Information Applications Due: January 3, 2018, 5:00 PM ET Before the form is completed, you may click "Save & Continue" at the bottom of the

More information

SCHOOL OF NURSING POLICY

SCHOOL OF NURSING POLICY SCHOOL OF NURSING POLICY SUBJECT: Academic Affairs TITLE: Graduate Program Student Scholarship Responsible Executive: Assistant Dean for Graduate Programs Responsible Office: Business Office CODING: 06-01-05-16:00

More information

Instructions for completion and submission

Instructions for completion and submission OMB No. 1121-0094 Approval Expires 01/31/2019 Form CJ-5A 2018 ANNUAL SURVEY OF JAILS PRIVATE AND MULTIJURISDICTIONAL JAILS FORM COMPLETED BY U.S. DEPARTMENT OF JUSTICE BUREAU OF JUSTICE STATISTICS AND

More information

EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION EMPLOYMENT APPLICATION Page 1 of 3 This Employment Application will remain active for one year from the date of completion APPLICANT INFORMATION Last Name First M.I. Date Street Apartment/Unit # City State

More information

UNIVERSITY CITY FIRE & RESCUE DEPARTMENT (UCFR)

UNIVERSITY CITY FIRE & RESCUE DEPARTMENT (UCFR) 1 OVERVIEW OF THE UNIVERSITY CITY FIRE & RESCUE DEPARTMENT (UCFR) University City Fire & Rescue Department Telephone: (514) 911-0129 1000 Rescue Drive University, IA 50436 City Demographics: The city has

More information

BS in Nursing Science Registered Nurse Option Track

BS in Nursing Science Registered Nurse Option Track UAA School of Nursing (907) 786-4550 Phone (907) 786-4559 Fax uaa_nursestdtservice@alaska.edu BS in Nursing Science Registered Nurse Option Track APPLICATION FOR ADMISSION Application deadline: November

More information

H Alumni Camp Application

H Alumni Camp Application 2018 4-H Alumni Camp Application Due May 18, 2018 Camp Registration $75 Make checks payable to Boone County 4-H Sr. Council Name County of Alumni Membership Age Date of Birth Male Female Address City State/Zip

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT HUMAN RESOURCE USE ONLY Date: Reactivation Date: APPLICATION FOR EMPLOYMENT As an equal opportunity employer, it is Bradley University policy that all persons shall have equal employment opportunity regardless

More information

Clarkson University Supplemental Application Class of 2021

Clarkson University Supplemental Application Class of 2021 Clarkson University Supplemental Application Class of 2021 There is no advanced placement in the Clarkson University PA program nor does the program accept transfer credit from a student previously enrolled

More information

RNDC does not discriminate on the basis of age, race, sex, creed, or disability. Equal Opportunity Lender

RNDC does not discriminate on the basis of age, race, sex, creed, or disability. Equal Opportunity Lender PLEASE PRINT CLEARLY OR TYPE: DEPARTMENT OF BUSINESS AND INDUSTRY HOUSING DIVISION WEATHERIZATION ASSISTANCE PROGRAM APPLICATION A. APPLICANT INFORMATION HOME WORK NAME: PHONE: PHONE: (Last, First, MI)

More information

CHECK ALL DEPARTMENTS OF INTEREST: CAFETERIA BUS DRIVER PRIME TIME

CHECK ALL DEPARTMENTS OF INTEREST: CAFETERIA BUS DRIVER PRIME TIME CLASSIFIED EMPLOYMENT APPLICATION AUXILIARY SERVICES POSITION APPLIED FOR: CHECK ALL DEPARTMENTS OF INTEREST: CAFETERIA BUS DRIVER PRIME TIME Per CCS Regulation 6315/7400-R Classified Personnel Requirement

More information

Athens Mayor s Youth Commission New Applicant

Athens Mayor s Youth Commission New Applicant Athens Mayor s Youth Commission 2017 - New Applicant Application Deadline: Friday, Sept. 15, 2017, at 4:30 p.m. Purpose: The vision for the Athens Mayor s Youth Commission is to empower caring youth dedicated

More information

College of Lake County Children s Learning Center Child Care Access Means Parents in School CCAMPIS Grant Application (Please print or type)

College of Lake County Children s Learning Center Child Care Access Means Parents in School CCAMPIS Grant Application (Please print or type) CCAMPIS# Date Received College of Lake County Children s Learning Center Child Care Access Means Parents in School CCAMPIS Grant Application (Please print or type) Approved Denied: Date: 1. Student-parent

More information

HOMELESS VETERAN REGISTRY NORTHWEST MINNESOTA

HOMELESS VETERAN REGISTRY NORTHWEST MINNESOTA STATE OF MINNESOTA MINNESOTA DEPARTMENT OF VETERANS AFFAIRS HOMELESS VETERAN REGISTRY NORTHWEST MINNESOTA TENNESSEN WARNING YOUR PRIVACY RIGHTS The State of Minnesota and its partners have committed to

More information

If applying for Testing Accommodations under the Americans with Disabilities Act (ADA):

If applying for Testing Accommodations under the Americans with Disabilities Act (ADA): Florida Certified Nursing Assistant Examination Application *APPCNAFL* Instructions: Please go to www.prometric.com/nurseaide/fl to print the current version of this application and all other forms. DO

More information

Division of State Fire Marshal Rhode Island Fire Academy 4 Green Lane, Exeter, RI Tel: (401) Certification Examination Application

Division of State Fire Marshal Rhode Island Fire Academy 4 Green Lane, Exeter, RI Tel: (401) Certification Examination Application Division of State Fire Marshal Rhode Island Fire Academy 4 Green Lane, Exeter, RI 02822 Tel: (401) 294-5417 Certification Examination Application PERSONAL INFORMATION Name: Address: City: Telephone: E-mail

More information

U.S. Merchant Marine Academy 300 Steamboat Road, Kings Point, New York CANDIDATE APPLICATION PART 1

U.S. Merchant Marine Academy 300 Steamboat Road, Kings Point, New York CANDIDATE APPLICATION PART 1 U.S. Merchant Marine Academy 300 Steamboat Road, Kings Point, New York 11024-1699 CANDIDATE APPLICATION PART 1 This collection of information is required to obtain benefits and will be used to determine

More information

Scholarship Application Due October 31, PM ET/5PM PT

Scholarship Application Due October 31, PM ET/5PM PT Scholarship Application Due October 31, 2017 8PM ET/5PM PT About AIDSWatch: AIDSWatch is the largest annual national constituent-based advocacy event focused on HIV policy in the United States. The event

More information

Crothall Services Group Environmental Services / Housekeeping

Crothall Services Group Environmental Services / Housekeeping Crothall Services Group Environmental Services / Housekeeping Application Information Please retain this sheet for future reference - Positions for Housekeeping are staffed through Crothall Services Group,

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT APPLICATION FOR EMPLOYMENT PO Box 499 Zephyr Cove, NV 89448 128 Market Street, Ste 3-F Stateline, NV 89449 www.tahoetransportation.org FOR PERSONNEL USE ONLY Input Qualified Best Qualified Not Qualified

More information

Application Deadline: Tuesday, April 25, 2017

Application Deadline: Tuesday, April 25, 2017 Career and Technical Education (CTE) Summer Youth Internship Program We are proud to announce the Summer Youth Internship program co-sponsored by the City of Fayetteville, the Public Works Commission (PWC)

More information

Application for Training and Technical Assistance to Implement the Lethality Assessment Program Maryland Model (LAP) INSTRUCTIONS. Project Description

Application for Training and Technical Assistance to Implement the Lethality Assessment Program Maryland Model (LAP) INSTRUCTIONS. Project Description INSTRUCTIONS Project Description Application for Training and Technical Assistance to Implement the Lethality Assessment Program Maryland Model (LAP) Page 1 of 23 INSTRUCTIONS This project was supported

More information

Wyoming Certified Nursing Assistant Examination Application

Wyoming Certified Nursing Assistant Examination Application *APPCNAWY* Wyoming Certified Nursing Assistant Examination Application Instructions Please go to www.prometric.com/nurseaide/wy to print the current version of this application and all other forms. DO

More information

Employment Application

Employment Application PERSONAL RECORD (Please print or type) FULL LEGAL NAME AS IT APPEARS ON YOUR SOCIAL SECURITY CARD OTHER NAMES USED IN /EDUCATION NAME YOU PREFERRED TO BE CALLED MAILING ADDRESS (P.O. BOX/STREET.) CITY

More information

NEW MEXICO EMS PROVIDER 2017 LICENSURE RENEWAL APPLICATION

NEW MEXICO EMS PROVIDER 2017 LICENSURE RENEWAL APPLICATION PLEASE PRINT OR TYPE APPLICATIONS MUST HAVE ORIGINAL SIGNATURES NM EMS License # * SSN of Birth Last Name First Name Middle Initial Gender: Male Female Has your name changed since your last renewal? Yes

More information

RESPITE CARE VOUCHER PROGRAM

RESPITE CARE VOUCHER PROGRAM HELPING HANDS of VEGAS VALLEY 2320 Paseo Del Prado B-204, Las Vegas, NV 89102 (702) 633-7264 ext. 26 or Fax (702) 728-2963 RESPITE CARE VOUCHER PROGRAM Dear Applicant: Thank you for your interest in the

More information

The College of Science & Mathematics &CGCE Department of Nursing Application Admission

The College of Science & Mathematics &CGCE Department of Nursing Application Admission The College of Science & Mathematics &CGCE Department of Nursing Application Admission 2013-2014 Who should use this application form? This application is intended for the licensed Registered Nurse (RN)

More information

UNIVERSITY CITY FIRE & RESCUE DEPARTMENT (UCFR)

UNIVERSITY CITY FIRE & RESCUE DEPARTMENT (UCFR) 1 OVERVIEW OF THE UNIVERSITY CITY FIRE & RESCUE DEPARTMENT (UCFR) University City Fire & Rescue Department Telephone: (514) 911-0129 1000 Rescue Drive University, IA 50436 City Demographics: The city has

More information

Employee EEO Self-Identification Form

Employee EEO Self-Identification Form CONFIDENTIAL Employee EEO Self-Identification Form Notice - Completion of this form is voluntary. We are an Affirmative Action, Equal Opportunity Employer. Our employment decisions are made without regard

More information

CDBG PUBLIC SERVICES

CDBG PUBLIC SERVICES CDBG PUBLIC SERVICES Grant Application Submittal Instructions APPLICATIONS MUST BE RECEIVED BY: 5:00 p.m. Friday, January 27, 2012 DELIVER TO: Community Services Department Housing & Community Development

More information

Ethnic Minorities and Women s Internship Grant Guidelines

Ethnic Minorities and Women s Internship Grant Guidelines Ethnic Minorities and Women s Internship Grant Guidelines CONTENTS Mission and purpose... 1 Eligibility... 1 Administration and budget... 1 Funding overview... 1 Timeline... 2 Call for proposals... 2 Selection

More information

Position Title: Pediatric Nurse Practitioner-Lafayette, IN. Status: Full-Time

Position Title: Pediatric Nurse Practitioner-Lafayette, IN. Status: Full-Time Position Title: Pediatric Nurse Practitioner-Lafayette, IN Status: Full-Time Salary: $85,000.00 to $120,000.00/year Riggs Community Health Center is seeking highly trained, independent Pediatric Nurse

More information

St. Mary s Health Professions Academy Student Application

St. Mary s Health Professions Academy Student Application St. Mary s Health Professions Academy Student Application Tenth and eleventh grade students in tri-state area who are interested in a health care career will be considered for the St. Mary s Health Professions

More information

INSTRUCTIONS FOR CACFP - CHILD CARE CENTER REVIEW

INSTRUCTIONS FOR CACFP - CHILD CARE CENTER REVIEW INSTRUCTIONS FOR CACFP - CHILD CARE CENTER REVIEW Sponsoring organizations use this form, or alternate, to determine if participating sites are in compliance with the Child and Adult Care Food Program

More information

Other submitted/received documentation (check all that apply): Current Immunizations Student Records Photo ID

Other submitted/received documentation (check all that apply): Current Immunizations Student Records Photo ID * *An enrollment can include either a new enrollment, a re-enrollment or a transfer from other Pittsburgh Public Schools building. PPS Personnel ONLY: Date Received: Date Processed: Student ID#: School

More information

WHITMAN COUNTY CIVIL SERVICE COMMISSION

WHITMAN COUNTY CIVIL SERVICE COMMISSION WHITMAN COUNTY CIVIL SERVICE COMMISSION In compliance with Federal and State equal employment opportunity guidelines, qualified applicants are considered for employment without regards to race, creed,

More information

2018 State Funded Youth Employment Program

2018 State Funded Youth Employment Program 2018 State Funded Youth Employment Program APPLICATION OF INTEREST Completion of this application does not guarantee a slot in the program. This program is currently PENDING funding. Youth will be notified

More information

Grant Application Package

Grant Application Package Grant Application Package Opportunity Title: Offering Agency: CFDA Number: CFDA Description: Opportunity Number: Competition ID: Opportunity Open Date: Opportunity Close Date: Agency Contact: Research

More information

Instructions for completion and submission

Instructions for completion and submission OMB No. 1121-0094 Approval Expires 01/31/2019 Form CJ-5 2017 ANNUAL SURVEY OF JAILS FORM COMPLETED BY U.S. DEPARTMENT OF JUSTICE BUREAU OF JUSTICE STATISTICS AND ACTING AS COLLECTION AGENT: RTI INTERNATIONAL

More information

Capacity Building Grants: Education Contact Information

Capacity Building Grants: Education Contact Information Capacity Building Grants: Education Contact Information Please remember to view the RFA and complete instructions on our website. Letter of Intent Due: February 14th, 2018, 5:00 PM ET Before the form is

More information

A CDL Permit (Commercial Driver s License permit) is required for dispatch (job assignment) in the apprenticeship program

A CDL Permit (Commercial Driver s License permit) is required for dispatch (job assignment) in the apprenticeship program Information required for a complete application: Completed Application (must be signed and dated) Completed Work History sheet Proof of Age (copy of driver s license recommended) EEOC form Apprenticeship

More information

Survey of Program Training Needs (TCU PTN) Program Director Version (TCU PTN-D)

Survey of Program Training Needs (TCU PTN) Program Director Version (TCU PTN-D) Survey of Program Training Needs (TCU PTN) Program Director Version (TCU PTN-D) To be completed by Program Director Please answer the following questions by filling in the circle that describes your substance

More information

Applicant Information

Applicant Information POSITION APPLIED FOR: DATE City of Coos Bay at your service Applicant Information NAME Last First Middle ADDRESS CITY STATE ZIP TELEPHONE Home Message Work Cellular Best time to call: At work At home May

More information

HELENE FULD COLLEGE OF NURSING

HELENE FULD COLLEGE OF NURSING HELENE FULD COLLEGE OF NURSING APPLICATION FOR GENERIC BACHELOR OF SCIENCE (MAJOR IN NURSING) 24 East 120th Street, New York, NY 10035 Tel: 212-616-7200 Fax: 212-616-7299 www.helenefuld.edu PART I - BIOGRAPHICAL

More information

Pfeiffer University Department of Nursing Application to Undergraduate Upper Division Nursing Major

Pfeiffer University Department of Nursing Application to Undergraduate Upper Division Nursing Major Pfeiffer University Department of Nursing 2017 Application to Undergraduate Upper Division Nursing Major *Applicant: (Please print name) *Applications received or postmarked after February 1, 2017 will

More information

RN-to-BSN PROGRAM APPLICATION

RN-to-BSN PROGRAM APPLICATION RN-to-BSN PROGRAM APPLICATION Personal Information Please provide your legal name below Middle Social Security Number Date of Birth Email Gender Religious Preference I am applying for the term beginning:

More information

If applying for Testing Accommodations under the Americans with Disabilities Act (ADA):

If applying for Testing Accommodations under the Americans with Disabilities Act (ADA): *APPCNALA* Louisiana Certified Nurse Aide Examination Application Instructions Please go to www.prometric.com/nurseaide/la to print the current version of this application and all other forms. DO NOT submit

More information

CENTRAL GEORGIA ELECTRIC MEMBERSHIP CORPORATION EMPLOYMENT APPLICATION

CENTRAL GEORGIA ELECTRIC MEMBERSHIP CORPORATION EMPLOYMENT APPLICATION CENTRAL GEORGIA ELECTRIC MEMBERSHIP CORPORATION EMPLOYMENT APPLICATION Central Georgia EMC is an EOE/AA: Minorities/Females/Disabled/Vets employer and drugfree work place. Individuals who need an accommodation

More information

Juvenile Services Officer Application Information

Juvenile Services Officer Application Information JUVENILE SERVICES CENTER Danny L. Glick 13794 Prairie Center SHERIFF Cheyenne, WY 82009 Juvenile Services Officer Application Information IMPORTANT- Applicants should read through the application instructions

More information