Name* (First, M.I.,Last):
Are you 18 yrs or older?
References: Please give only references which you have known for at least 5 years. (no Clergy, family members or Corps members)
Name of Friend or Relative in the Corps (if any):
Have you any objections to this organization making inquiries regarding your character and qualification from:
A. Former employer?:
B. Present employer?:
If answer is "Yes" to either (a) or (b) , please explain:
List your level of experiences including certificates and licensing pertaining to the medical profession (CFR, EMT-D, EMT-I OR EMT-P, ETC.) :
Except for minor traffic violations, were you ever been convicted of any violation of the law?
Current or former member of an Ambulance Corps or Rescue Squad?
Do you have any physical disabilities or limitations?
Which shift would you prefer to ride? Select one:
6AM to Noon Noon to 6PM 6PM to Midnight
What day or days would be most convenient for you?
Mon Tue Wed Thurs Fri Sat Sun
Declaration: subject to the penalties of perjury, that the above statements made in this application have been examined by me and to the best of my knowledge are true and accurate. I declare,