Application Fee is $15.00. Due at the time of meeting with Investigation Committee.
Application Info
Date/Time:
Type of Application:
Check Membership Applying for:
Personal Information
First Name:
Middle Initial:
Last Name:
Other Names (Alias, Maiden, etc.):
Date of Birth:
Address:
City:
State:
Zip:
Telephone:
E-mail Address:
Marital Status:
Additional Information
Do you have a Driver's License?:
Number:
Class:
State Issued:
Emergency Contact
Contact Name:
Contact Relationship:
Contact Phone:
References
Reference 1:
Phone Number 1:
Reference 2 :
Phone Number 2:
Reference 3:
Phone Number 3:
Background Information
Have you been convicted or plead guilty to a misdemeanor/felony? :
If yes, list all offenses and state date, place and action taken:
Training (Please submit copies of any certifications you hold for any EMS/Fire Training and course work completed including dates of completion and/or expiration.)
Please Include all training Including (Training Level) (MFRI / MIEMSS I.D. Number) (Completed or Expiration Date):
Please add copies of your certifications here:
Employment
Are you currently employed :
Place of Employment:
ADDITIONAL RESCUE SQUAD/EMS/ALS/FIRE INFORMATION
Are you a member of another Rescue Squad, EMS,ALS or Fire Department?:
Have you ever been a member of another RescueSquad, EMS, ALS or Fire Department?:
If yes, explain:
Attach a list of all Rescue Squad, EMS,ALS or Fire Department organizations to which you were either a paid and/or volunteer member. Include date (from/to), and any offices held:
Background Check Statement
I grant the Investigation Committee permission to perform investigative interviews, including background checks to obtain membership. Any findings may be made public at the monthly meeting and may have direct impact on my application for membership. :
