MEMA Disaster Reservist Program

Disaster Reservist Application

Mississippi Emergency Management Agency
Full Name (as appears on Driver's License)

First NameMiddle NameLast Name
Address

Street Address

County

CityState / Province

Postal / Zip CodeCountry
E-mail
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Availability
When can you start work

MonthDayYear
Are you willing to travel away from home for:
Are you willing to accept an assignment on short notice?
Are you willing to accept an assignment that may cause you to have to be away from home during holidays?
Are you willing to live in primitive conditions? (camping out)
Are you a retiree on the Mississippi Public Employees Retirement System (PERS)?
Date retired from PERS (if applies)

MonthDayYear
Are you a member of the Mississippi National Guard
Do you have any experience using Web-EOC?
1. Employment Details
Date Employed From

DayMonthYear
Date Employed To

DayMonthYear
Job Title
Comments/further information
2. Employment Details
Date Employed From

DayMonthYear
Date Employed To

DayMonthYear
Job Title
Comments/further information
Education:
Please list any education experience. - School Name
City, State Course of Study Graduate? Dates
Special Training
If you have completed any courses or training related to this type of work,give information below
Which of the following positions do you have experience, education, and/or training that qualifies you to serve during a disaster response/recovery?
Please attach any informatoin that you feel would be important to share.

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Street Address

County

CityState / Province

Postal / Zip CodeCountry
Should be Empty:

Disaster Reservist Application

Availability

1. Employment Details

2. Employment Details

Education:

Special Training