CITY OF LAMAR, COLORADO
PERSONAL INFORMATION FORM FOR CANDIDATE FOR THE PUBLIC SAFETY BOARD
Name
*
First Name
Middle Name
Last Name
Street Address
*
City
*
Zip Code
*
Home Phone
Home
Cell Phone
*
Home
Email Address
example@example.com
City Resident?
*
Yes
No
How long?
*
Occupation
*
Education Background
*
Are there any reasons you may have a conflict of interest if you were appointed to this Board or Commission?
*
Yes
No
If you answered Yes above, please explain:
*
Is there any information (experience, community, activities, organizations, etc.) which you think should be considered for your appointment to this Board or Commission
*
Why do you desire to serve on this Board or Commission
*
Briefly describe how you might benefit the community if you were selected to serve on this Board or Commission
*
Are you currently aware of the operations of Lamar Fire & Ambulance Services?
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Yes
No
If not, are you willing to go through a brief operations overview to assist you in helping on this board?
*
Yes
Yes
Are you aware of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) and how it is applied to the Lamar Fire and Emergency Services, and subsequently, to the information you maybe exposed to during the course of your possible appointment to this board?
*
Yes
No
Do you understand you will be required to attend a training hosted by Lamar Fire and Emergency Services on the applicability of HIPPA?
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Yes
No
Are you aware of Medical Guidelines, Standard Operating Procedures (SOP’s), Medical Direction, Fire Codes, and how they are applied to the operations of the Lamar Fire and Emergency Services?
*
Yes
No
Do you understand that you will need to be orientated to all applicable documents?
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Yes
No
Have you been (or are currently) affiliated with another Fire or EMS service?
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Yes
No
If yes, please list all previous or current affiliations and approx. dates of service
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/
Month
/
Day
Year
Date
Are you willing to perform up to 24 hours of our 3rd rider program to assist you in understanding the operations of the Lamar Fire and Emergency Services?
*
Yes
No
Do you have an understanding of police and fire operations?
*
Yes
No
If yes, please explain
*
I authorize and consent to the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making an appointment decision.
*
Initial Here
I release such persons and organizations from any legal liability in making such statements.
*
Initial Here
DATE
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Month
/
Day
Year
Date
SIGNATURE
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