MADISON COUNTY HEALTH DEPARTMENT

Emergency Service and Disaster Oath

Madison County E.S.D.A.

I, ,  do solemnly swear (or affirm) that I will support and defend and bear true faith and

allegiance to the Constitution of the United States and the Constitution of the State of Illinois and the territory, institutions and facilities

thereof, both public and private, against all enemies, foreign and domestic; that I take this obligation freely, without any mental reservation

or purpose of evasion; and that I will well and faithfully discharge the duties upon which I am about to enter. And I do further swear (or affirm)

that I do not advocate, nor am I, nor have I been a member of any political party or organization that advocates the overthrow of the government

of the United States or of this State by force or violence; and that during such time as I am affiliated with the Madison County E.S.D.A., I will

not advocate nor become a member of any political party or organization that advocates the overthrow of the government of the United States

or this State by force or violence.




Signature of Appointee:       Date of Birth:       Phone Number:


City:            State:             Zip Code:  


                                                                                                                                                                                               



Printed Name of Person Authorized to Administer Oath: Larry Ringering, Madison County EMA

Authorized Signature:       Date:      

Please confirm by correctly answering the following security question:
What is the first letter of the English alphabet?

Return Form to:
Debra M. Tscheschlok R.N., B.S.N.
Madison County Health Department
101 E. Edwardsville Road
Wood River, IL 62095

OR submit by clicking "Submit" button below


     
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