EMERGENCY VEHICLE ASSISTANCE COMMUNICATIONS, INC. EVAC, Inc

EMERGENCY VEHICLE ASSISTANCE &COMMUNICATIONS, INC.

EVAC, Inc.P.O. Box 5283 S.U.S.

FARGO, NO 58105

Application Acknowledaement and Release

EMERGENCY VEHICLE ASSISTANCE COMMUNICATION

THIS APPLICA TION DOES NOT CONSTITUE A WRITTEN MEMBERSHIP AGREEMENT.

In the event that the applicant meets the membership requirements of EVAC Inc, the applicantagrees that that the relationship between EVAC and the member is an at-will relationship and thatEVAC Inc has the right to terminate the member with or without cause, and with or without notice, atany time, at the option of either EVAC Inc or the member.

I certify that all the information provided in this application is accurate and correct to the best of myknowledge. If EVAC Inc determines that any information submitted in this application is false, I shallbe immediately disqualified from consideration for membership and/or discharged from membershipin accordance with EVAC Inc's policy.

I hereby understand and authorize EVAC Inc to thoroughly investigate my background, driver'slicense information, my work and personal history and verify all dates given in this application. Iauthorize all individuals, schools, past & present employers, to provide any information requestedabout me and I release them from liability for damage in providing this information. I also releaseEVAC Inc, its board of directors, general members and any of its agents or any other person actingon behalf of EVAC Inc, from any and all liability related to the investigation of the informationcontained in this application, related papers and in interviews.

I represent and certify that I have read and fully understand the above mentioned statements andthat I seek membership under these conditions.

Signature of Applicant Date



FARGO, NO 58105

Background & Driver's License Check


I understand that EVAC Inc. will run a criminal background check as well as a driver's license checkon me as condition of acceptance for membership in EVAC Inc. I also understand that these arerequirements for continued membership and that EVAC Inc. reserves the right to periodically runcriminal background checks and/or driver's license checks as necessary at anytime during mymembership. I therefore authorize EVAC Inc. and its representatives to investigate my backgroundand driver's license information.

Signature: Date:

I understand that an acceptable background history and acceptable driver's license history arerequirements for membership and continued membership in EVAC Inc. I further understand that Imay be terminated at any time for not meeting the aforementioned requirements. I also understandthat any change in status in the aforementioned requirements, must be reported to the EVAC ChiefAdministrator immediately.

Signature: Date:

I understand that as a member of EVAC Inc., I have the potential to be exposed to sensitive and/orconfidential experiences. I further understand that I will NOT speak of or mention any of theseexperiences to anyone outside of EVAC Inc., unless directed to under legal subpoena.

Signature: Date:

I understand that EVAC Inc. is an emergency assistance agency that provides 24 hour, 7 day aweek readiness for potential calls for service. I also understand that these calls for service tend tohappen at less than convenient times and may infringe upon my own personal life at times. I furtherunderstand that this infringement is necessary to aid and assist local Law Enforcement, FireDepartment & EMS agencies in the performance of their duties as well as to help insure their safety,and to assist in the protection of life and/or property.

Signature: Date:



FARGO, ND 58105

Eauipment Utilization Statement


I understand that EVAC Inc will provide me with the basic necessary equipment needed to performthe tasks assigned. These items may include but not limited to; mobile radio, portable radio, pagers,lightbar with blue color, North Dakota Blue Light Card, Cass County Identification Badge, vehicledoor placards, traffic cones, reflective vest, uniform shirt & three ring binder containing by-laws,policy & procedures. I understand that in the event I become separated from EVAC Inc, regardlessof reason why, I will immediately return all EVAC Inc owned equipment. I further understand thatfailure to return the aforementioned equipment will result in my criminal prosecution.

Signature: _ Date: _

I understand that as a member of EVAC Inc and providing I have passed the necessaryprobationary period, I may elect to purchase my own mobile and/or portable radio equipmentcontaining radio frequencies licensed to or granted to EVAC Inc and/or emergency lightingcontaining the colorblLJe. I further understand that in the event I become separated from EVAC Inc,regardless of reason why, I will immediately have all two-way radio communications equipmentreprogrammed so as to remove all EVAC licensed and granted radio communication frequencies(both transmit and receive frequencies) from said radios, and will provide written documentation thatsuch actions has taken place. I further understand that any emergency lighting equipmentcontaining the color blue, will be altered in such a manner so as to remove or eliminate all bluecolor, regardless of style or type of lighting. I also understand that failure to comply with theaforementioned stipulation will result in my criminal prosecution.

Signature: _ Date: _



FARGO, NO 58105

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EVACEMERGENCY VEHICLE ASSISTANCE COMMUNICATION

Please sign all forms amd mail this application to the address above or hand it to an EVAC member.

Personnel Application FileFull Name

Address

Date of Birth

Social Security No.

Marital Status

Phone No.

City

Unit Number Assigned

State Zip Code

Cell Phone No.

Drivers License No.

Spouse's Name

Phone No.Q)

Ecoz1iico

....J

In Case Of Emergency, Please Contact

Employer Name

Address

Date Joimed EVAC Inc.

Reason for Separation

Position

City

Date Separated From EVAC Inc.

State

Q)

Ecoz

1iiL..

u::

Item

Equipment Issued:Serial No. or Size Date Issue Date Returned

EMERGENCY VEHICLE ASSISTANCE COMMUNICATIONS, INC. EVAC, Inc

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