All fields below are required.

First Name

Last Name

Position/Title

Agency

Phone

Email

Address, City, ST, Zip

Requested Password (Must be at least 8 characters in length and can include letters, numbers, and symbols. Password will be case-sensitive)

Re-Type Password

By submitting this request for security clearance I understand and agree with the following:

• I understand the use of security classifications are for the protection of the public to ensure responses to disasters and emergencies are not compromised and is for the protection of the privacy of response personnel as contact information and other private information may be stored in the response plan for use during a disaster or emergency.

• I agree not to disclose confidential, secret, or top secret information, my user name, or password to anyone else for any reason and take all reasonable measures to prevent said disclosure. All requests for information should be forwarded to the health department administrator or this page for a request for clearance.

• I understand that any documents printed or otherwise stored away from this system carries the same need for security. Hard-copy documents retrieved and bear confidential, secret, or top secret at the top and bottom are still to be treated as restricted information for my use only and should be destroyed after use.

• I understand that my obligation under this agreement will continue after my termination of employment and/or association with the agency listed above. I agree to immediately notify the Polk County Health Center of my termination and return or destroy all hard-copies and my access to the electronic documents may be revoked.

• I understand that my user name and password are the equivalent of my signature and that I am accountable for all entries and actions recorded during their use.

Violation of this agreement may result in, but not limited to, the following:

• Denial of access;

• Notification of employer;

• Disciplinary action as allowed by my employer;

• Penalties under State and Federal laws and regulations;

• Any combination of the above.

By checking here, dating, and clicking "Submit" below:

• I consent to the Polk County Health Center contacting my employer for employment verification;

• I have read and understood the above security clearance agreement; AND

• I agree with all items listed in the security clearance agreement.

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(Clicking here will attempt to send the above information with your email application, if it fails, please manually email with the above information.)