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

The following information is the minimum information required to register as an emergency worker:

Historical Note

Section made by final rulemaking at 14 A.A.R. 4519, effective January 31, 2009 (Supp. 08-4).