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Broward County Medical Reserve Corp. Volunteer Application
Broward County MRC Home Page
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Prefix
Adm
Atty
Brother
Capt
Chief
Cmdr
Col
Dean
Dr
Elder
Father
Gen
Gov
Hon
Lt Col
Maj
MSgt
Mr
Mrs
Ms
Prince
Prof
Rabbi
Rev
Sister
Name
*
First
Middle
Last
Suffix
II
III
IV
CPA
DDS
Esq
JD
Jr
LLD
MD
PhD
Ret
RN
Sr
DO
Birthday
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
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11
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22
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30
31
/
YYYY
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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2006
2005
2004
2003
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1991
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
Male
Female
Height
Weight
Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone#1
*
Phone#2
Email
*
Emergency Contact Name
*
Relationship
Emergency Contact Phone#
*
What type of volunteer position are you interested in? (Check all that apply)
*
Emergency Response
Non-Medical Administration
Unit Administration
Community Involvement
Special Events
Other
If you selected "Other" for volunteer position, please describe below
List all professional license, registration, or certificate you currently possess (include certificate/license number(s)):
Occupation1
Occupation2
License#1
License#2
Exp. Date#1
Exp. Date#2
Do you have more Occupations to enter?
Yes
No
If yes, please provide details
List any special skills or certifications
List any Special Considerations or needs
List two personal references not related to you whom you have known for more than one year:
Name of 1st Reference
First
Last
Address of 1st Reference
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone# for 1st Reference
Name of 2nd Reference
First
Last
Address of 2nd Reference
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone for 2nd Reference
List your most recent most volunteer or employment experience:
Employer
Employer Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Employer Phone
Job Title
Date Started
Date Ended
Select todays date if still employed or volunteering at this location
Specify the days and time frames you are available to volunteer (Check all that apply):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Select Date you can start
Select Date you need to stop
Have you ever been convicted of or plead nolo contendere to a driving or criminal offense?
*
Yes
No
If answer is yes, please explain (including types of offenses and dates):
It shall be a misdemeanor of the first degree to fail to disclose, by false statement, misrepresentation, impersonations or other fraudulent means, any material fact used in making a determination as to a person’s qualifications to work as a volunteer. I understand that, to protect persons served by the department, a routine check through law enforcement, license bureaus, agency files, and references may be made. I understand that a criminal offense will not automatically exclude me from all volunteer positions; however, certain convictions will exclude me from volunteering in some positions. I understand that if I answered no to the criminal offense question on the front of this application and a record should be obtained, it will prevent me from volunteering for the department regardless of the offense. I understand upon submission of this application it becomes public record. I understand and agree that all information as it relates to persons served by the department is to be held confidential in compliance with Florida Statutes. All information that should come to my attention and knowledge as privileged and confidential will not be disclosed to anyone other than authorized personnel and that I shall conduct myself in accordance with the departmental security policies. I understand that failure to comply may result in criminal prosecution. I affirm that all information on this application is true and correct.
Signature
*
Clear Signature
Todays Date
*
Submit