Haz-Mat Team Application

Greene County Hazmat Team Application

Full Name:*

E-mail:*

Telephone Number:*

Address:*

Date of Birth*

MonthDayYear

Name of Sponsor #1 (sponsor must be a member of the HazMat team)

First NameLast Name

Sponsor #1 Phone Number

Area CodePhone Number

Name of Sponsor #2 (sponsor must be a member of the HazMat team)

First NameLast Name

Sponsor #2 Phone Number

Area CodePhone Number

Fire Company/Department Affiliation:*

Fire Company/Department Affiliation*

The team will need your department/company fire chief to fill out the "Haz-Mat Team Member in good standing and Respirator Use Clearance Form " at:

https://form.jotform.com/210756166150956

Last OSHA Physical:*

Physical by Whom:*

Prior DECON Team/HazMat Training (please list)*

NY State Fire Training ID# (Example NY0000000)*