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Volunteer Emergency Responder
Dodge County
Emergency Operations
Membership Application Form
Personal Information
Name
Email
Mobile
Address
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Candidate Demographics
Middle Initial
Date of Birth
Are you a US Citizen?
Yes
No
Do you reside within Dodge County?
Yes
No
Have you ever worked for Dodge County Emergency Response Team Inc.?
Yes
No
Background Information
Have you ever been convicted of a felony, misdemeanor or criminal traffic violation?
Yes
No
Have you ever been charged with a violent crime, domestic abuse, or a sex crime?
Yes
No
Have you ever been convicted of an OWI (Operating While Intoxicated) or DUI (Driving Under the Influence)?
Yes
No
Do you have any felony, misdemeanor or criminal traffic charges pending against you?
Yes
No
Have you been convicted of more than 2 traffic violations in the past 5 years?
Yes
No
Do you have physical or mental limitations that would prohibit you from fulfilling the duties of the position you are applying for? If yes, please explain below in the 'Other Pertinent Information' section.
Yes
No
Do you have an unrestricted and unconditional WI Class D Driver's License?
Select an Option
Yes
No - My License is Suspended
No - My License is Revoked
No - I Have An Occupational License
No - I do not have a Class D Driver's License
Additional Information
Do you currently hold a valid Peace Keeper, EMS, TEMS, or Firefighter license with the State of Wisconsin?
Yes, Peace Keeper
Yes, EMS
Yes, EMS with TEMS endorsement
Yes, Firefighter
No
Do you currently hold FEMA ICS 100, 200, 700 or WI TIMS Certifications?
Yes, ICS 100
Yes, ICS 200
Yes, ICS 700
Yes, WI TIMS
No
Would you be able to obtain the previously listed FEMA and/or WI TIMS certification(s) within your first year?
Yes
No
What is your typical availability to respond to calls for service/assist with events?
M-F Days
M-F Evenings
M-F Nights
Weekend Days
Weekend Evenings
Weekend Nights
Are you able to provide a minimum of 40 hours of annual service?
Yes
No
Why do you wish to join Dodge County Emergency Response Team, Inc.?
Other Pertinent Information
Voluntary Disclosures
Gender
Select an Option
Male
Female
Ethnicity
Select an Option
I do not wish to self-identify.
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Acknowledgements
Dodge County Emergency Response Team Inc. provides equal membership opportunities to all persons. All applicants will receive consideration for membership without regard to race, creed, religion, physical appearance, gender, color, sex, sexual orientation, gender identity/expression, national origin/ancestry, age, disability, marital status, political affiliation, disabled veteran status or other protected status. By clicking below I acknowledge this statement.
I hereby affirm that the information provided on this application (including any uploaded documents) is true and complete. I understand that any false or misleading representation or omissions may disqualify me from further consideration for membership and may result in discharge from membership if discovered at a later date. I understand that completion of this application does not assure me of a position with Dodge County Emergency Response Team Inc. By clicking below I acknowledge this statement.
I understand that this is an unpaid volunteer position, and that if selected, I will not be compensated.
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