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
audrey.shaver@cmich.edu




If you have any questions feel free to contact SVMCA
at 989-583-7937 .