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Emergency Preparedness - Credentialing - Request Photo ID

Photo IDs are provided to agencies in Missouri by the Polk County Health Center and Polk County Emergency Management. Agencies and individuals included are those that provide a public service and may respond to a disaster. Funding for IDs is provided by a bioterrorism grant through the Polk County Health Center, Missouri Department of Health and Senior Services, and the Centers for Disease Control and a homeland security grant through Polk County Emergency Management, Missouri State Emergency Management Agency, and the Department of Homeland Security. Information provided is entered into a state-wide responder database and may be distributed to emergency and governmental agencies in a time of disaster, emergency, or other event to verify responders, create a resource list, and/or ensure personnel accountability.

This form can also be downloaded, printed, and returned as a hard-copy if it is more convenient. (39 kb pdf)

If you are requesting a re-print or corrections to an ID, simply email with details.

1.	DSN (designated service number):
2.	Badge type:	*required
3.	Title:
4.	Security level:	*required
5.	Agency:	*required
6.	Last name:	*required
7.	First name:	*required
8.	Street address:
9.	City:
10.	State:
11.	Zip:
12.	Email address:
13.	Emergency contact name:	*required
14.	Emergency contact phone number:	(format: ###-###-####) *required
15.	Your mobile phone number:	(format: ###-###-####)
16.	Mobile carrier:
17.	Home phone number:	(format: ###-###-####)
18.	FCC call sign:
19.	Fire training:	*required
20.	EMS training:	*required
21.	HazMat training:	*required
22.	Additional barcode number to associate with this individual in the database:	(i.e. Employee ID Card barcode)

Send an email to with the mug shot or to schedule a time to take the picture. Please do not edit the original digital photo if you take your own pictures and email them.

Once the ID is printed, the agency administrator or designee will be contacted to arrange delivery or pickup of the ID.

Polk County Health Center
(417) 326-7250 voice
(417) 326-2766 fax

1317 W Broadway St
Bolivar, MO 65613

© 2003-2008 Polk County Health Center, Bolivar, Missouri. All rights reserved.
All services are provided on a nondiscriminatory basis. This institution is an equal opportunity provider and employer.
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write to the USDA, Director, Office of Civil Rights, 1400 Independence Avenue SW, Washington, DC, 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.
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