R8-2-703. Required Registration Information

The following information is the minimum information required to register as an emergency worker: 1. Full name; 2. Birth date; 3. Gender; 4. Social Security Number; 5. Citizenship, to include a document verifying citizenship; 6. Provide verification of eligibility to work in the United States; 7. Address; 8. Contact phone number and e-mail address; 9. Driver’s license number, issuing state and expiration date; 10. Registering jurisdiction; 11. Registering agency/organization; 12. Employer name, address and phone number; 13. Personal reference name, address and phone number; 14. Emergency contact name, address and phone number; 15. Professional licenses, certificates and registrations, to include numbers and expiration dates (copies will be provided); 16. Court record of felony convictions; 17. Record of misdemeanor convictions involving moral turpitude; and 18. Medical conditions which may limit ability to perform as an emergency worker.