I Hereby Certify That, Where Required, the Relevant Documents Have Been Attached

/ Application for Membership Form / FBMH 2.0.1
QueenslandState Emergency Service / In-Confidence
Official Use Only
REGION / AREA / SES MEMBERSHIP NO.
SES UNIT / SES GROUP
1. Personal Details
Title / Surname*as shown on official identification / Given Name/s*as shown on official identification / Preferred Name
Mr Ms
Mrs
Other
Gender / Male Female / Date of Birth / //
Australian Citizen / Yes No
2. Contact Details
Residential Address
Post Code
Postal Address (Insert “AS ABOVE” if same as Residential Address)
Post Code
Email
Contact Home / Mobile / Business
3. Emergency Contact Details
Name
Residential Address
Post Code
Contact Number / Mobile
Relationship
4. Equal Employment Opportunity/Diversity Information
People with a disability / Torres Strait Islander
People from a non English speaking background / Aboriginal / Australian South Sea Islander
5. Detail any Current/Previous Emergency Organisation Membership (eg SES, QFRS, RFS, QAS, QPS, VMR, Surf Life)
ID No. / Position (or Member) / Brigade/Group/District/Unit / State / Start Date
(DD/MM/YY) / Finish Date
(DD/MM/YY)
/ / / / /
/ / / / /
/ / / / /
/ / / / /
/ / / / /
6. Qualifications (relevant to SES activities)
Please attach copies of any certificates relevant to SES activities.
(eg Driver Licence, Occupational Health Safety Certificates, Certificate IV in Training and Assessment, Heavy Machinery Licence)
Copies attached / Yes No

I hereby certify that to the best of my knowledge the above details are correct. I agree to return all SES equipment and uniforms (including personal issue)on resignation or termination from the Queensland SES.

Signature of Applicant / Date / //

I hereby certify that, where required, the relevant documents have been attached.

SES Group leader
Name:
______/ Signature:
______/ Date:___ / ___ / ___
SES Local Controller Recommended / Not Recommended (attach document, if required, stating reason for not recommending applicant)
Name:
______/ Signature:
______/ Date:___ / ___ / ___
REGIONAL DIRECTOR(or delegate) Approved / Not Approved (attach document, if required, stating reason for not approving applicant)
Name:
______/ Signature:
______/ Date:___ / ___ / ___

Queensland Fire and Emergency Services is collecting the personal information on this form for the following purposes:

-to appoint State Emergency Service (SES) members;

-to manage the administrative and training support provided to SES members; and

-for the Department to discharge its legislative, accountability, administrative, reporting, management, personnel and financial functions.

Collection of this information is authorised/required by the Disaster Management Act 2003.

For further information about privacy and other uses and disclosures of your personal information, refer to the Department’s Privacy Plan as amended from time to time, available on the Department’s website.

/ Page 1 of 2 / Date: 05/02/2014 / FBMH 2.0.1 v2 /