Form Center • Chester County, PA • CivicEngage

Request for Appt of Municipal Emergency Mgmt Coordinator

INSTRUCTIONS
1. You must request a Criminal History Records Check for all who are recommended for appointment by completing a Pennsylvania State Police Form SP 4-164, "Request for Criminal Record Check." You must attach the results to this form.
PA SP 4-164 Request for Criminal Record Check
PA SP 4-164
2. Complete Part I
3. Click Print.
4. Forward this form and a copy of the Criminal Records Check results to Chester County Department of Emergency Services Attention Rob Linnenbaugh 601 Westtown Road, Suite 012 West Chester PA 19380 or scan and email to [email protected]
PART I
MUNICIPALITY INFORMATION:
Municipality Name:
Municipality Office Address:
Municipality Telephone Number:
Municipality Fax Number:
Previous Municipal Coordinator:
Appointment Date of Previous Coordinator
Appointment Date of Previous Coordinator
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Recommended Appointee Information:
Full Name:
Appointee's Home Address:
Appointee's Home Telephone Number
Appointee's Email Address:
Appointee's Date of Birth
Appointee's Date of Birth
Appointee's Social Security Number
The above recommendation is of record in the Minute Books of the Municipality and was made with due consideration of the qualifications of the above-recommended citizen and is subject to approval by the County, the Pennsylvania Emergency Management Agency, and the Governor of the Commonwealth of Pennsylvania.
Signature (Secretary/Manager)
Title:
Print Name:
Date
Date
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