Lincoln County, Maine OFFICE OF EMERGENCY MANAGEMENT
I.D. Application for Fire Departments, EMS, Local EMA, Town/County Officials
Fill out all information that applies to you and your Town/Agency/Department.
Full Name Last, First, MI
*
Title/Rank:
*
Town Department/Agency
*
Please Select
Alna
Boothbay
Boothbay Harbor
Bremen
Bristol
Damariscotta
Dresden
Edgecomb
Jefferson
Monhegan
Newcastle
Nobleboro
Somerville
South Bristol
Southport
Waldoboro
Westport Island
Whitefield
Wiscasset
Hazardous Materials Responder Level?
Awareness
Operations
Technician
None
S.C.B.A Qualified?
Yes
No
Firefighter
Basic
Firefighter 1 & 2
Firefighter 1
Firefighter 2
None
Incident Command System (ICS)
Basic: (ICS-100, ICS-700, ICS-800)
Intermediate (Basic Level Courses and ICS-200)
Advanced (Intermediate level courses and ICS-300, ICS-400)
None
Emergency Medical Technician/ Paramedic
Responder
Basic EMT
Advanced EMT
Paramedic
Emergency Medical License Number (If chosen above)
Date of License
/
Month
/
Day
Year
Date
*If Applying for EMS Transporting Provider Select Agency Here*
Please Select
BRAS
CLC
Waldoboro
Wiscasset
Local Emergency Manager?
YES
NO
BEM 1 or 2
CEM
Other Qualifications or comments
Date of Birth
/
Month
/
Day
Year
Date
Hair Color
*
Eye Color
*
Height
*
Weight
*
Cell Phone Number:
*
Home Phone Number:
Emergency Contact NAME:
*
Emergency Contact Phone Number:
*
Allergies and/or Medical History: (if anything important is wanting to be shared)
Reason for Request?
NEW
Updates
Changes
Replacements
NOTE: Authorized Persons will need to verify with LNEMA via email to authorize this I.D. and notify staff to look for this application.
Number of Badges Requested
1
2
3
Do you have clips for the IDs?
Please Select
Yes
NO
No Clue
Max of 2 Clips
Chief or Authorized Representative (note this person needs to verify with LNEMA)
*
Date Requested
/
Month
/
Day
Year
Date
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I attest to the accuracy and integrity of this document and all information to be true and not intentional or knowing falsification. A person who intentionally or knowingly falsifies, Provides false information, makes or alters any certificate or certified copy knowingly commits a crime and can be prosecuted under Maine State Law. Entering my name in the box below is a representation of my signature for this document - just the same as pen and paper signature.
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