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Law Enforcement Tag Information Form
*Required field
General Information
Last Name:
*
First Name:
*
Date of Birth:
*
Title/Rank:
*
Badge #:
*
Agency:
*
Date of Hire:
*
Emergency Contact 1:
Name:
*
Tx:
*
Emergency Contact 2:
Name:
*
Tx:
*
Home Address/Zipcode:
*
Phone # - Home:
*
Phone # - Work:
*
Height:
*
Weight:
*
Hair Color:
*
Eye Color :
*
Medical Information
Known Allergies:
*
Medical History:
*
Baseline Blood Pressure:
*
Hospital Preference:
*
Blood Type:
*
Certificate/Licenses
(Check all that Apply)
MCOLES:
Medical First Responder:
EMT:
EMT-P:
Dive Team Member:
Accident Investigation:
Fire Investigation:
Firefighter I/II:
Advanced Hazmat:
Confined Space Rescue:
Adv. Incident Command:
Patrol Rifle:
Evidence Tech:
Bomb Tech:
Heavy Equip Operator:
Respirator Certified:
SWAT Team Member:
Active Shooter Response:
Canine Handler: Explosives
Canine Handler:
Drugs
Canine Handler:
Tracking
Canine Handler:
Cadaver
Other:
After Submitting this form
please remember to email your pic to
mmora@synergymedical.org
If you have any questions feel free to contact SVMCA
at 989-583-7937 .