Please fill this application out completely. Any application containing false information will be dismissed.
Full Name __________________________________ Social Security Number ________________
Address ____________________________________ D.O.B. ___ /___ /___ Age ____
City ___________________ State _____ Zip _______ Highest Education ______________
Telephone (
HOME) ________________ (WORK) ________________ E-mail_____________________APPLICATION FOR:
Senior Squad
□ Junior Squad (16 but under 18 years) □ Associate □ Auxiliary □TRAINING:
E.M.T.
□ Shock Trauma □ Cardiac Technician □ Intermediate □ Paramedic □ EVOC □C.P.R.
□ First Responder □ OTHER _____________________________________________________Employer ____________________________________________________ Supervisor _________________
Address _____________________________________________________ Telephone ________________
REFERENCES:
List three references that could answer honestly about your work ethic, your moral character, and any other general questions that any member of the investigation committee should choose to ask. Examples include your employer, pastor, co-workers, teachers, community leaders, etc. Do not list present members of Dante Rescue Squad, Inc.Name _________________________________________________________ Relation ________________
Address ________________________________________________________ Phone _________________
Name _________________________________________________________ Relation ________________
Address ________________________________________________________ Phone _________________
Name _________________________________________________________ Relation ________________
Address ________________________________________________________ Phone _________________
ANSWER EACH OF THE FOLLOWING QUESTIONS. PLEASE PROVIDE AN EXPLINATION FOR ANY QUESTION YOU ANSWER YES TO. YOU MAY ATTACH OTHER SHEETS IF NECESSARY.
You must do a certain number of call shifts per month, depending on your classification of membership, when can you do the required shifts? ________________________________________
Have you had any criminal convictions, other than minor traffic violations? Yes
a. In accordance with OEMS regulations, certain criminal convictions may exclude applicant from membership (i.e. any form of child abuse, sexual misconduct, see 12 VAC 5-31-910 if needed)
b. We will conduct a character investigation of applicants.
c. This includes a criminal history check conducted by the State Police.
Do you have any physical defects that might keep you from doing your duties? Yes
□ No □Can you take orders and work well with others? Yes
□ No □Are you or have you ever been addicted to alcohol or other drugs? Yes
□ No □Do you have a driver’s license? Yes
□ No □ Provide a copy of your driving record from the D.M.VHave you ever been fired from a job? Yes
Are you proficiVent in reading and writing the English language? Yes
□ No □If accepted, I understand that my application will initially be placed on file for 30-days by the vote of the Senior Squad members. At the next business meeting, I understand that my application will be reviewed again and voted for 90-day probation to the squad. I further understand that my application will be reviewed at the end of the probation (in approximately 90 days).
I certify that I understand the above statements. I will follow all guidelines set forth by Dante Rescue Squad, Inc. and by the Virginia Office of Emergency Medical Services. I understand that stress may be involved in EMS (i.e. traumatic scenes, death, etc.).
Applicants Signature _______________________________________________ Date ___________
Parents Signature _________________________________________________ Date ___________
FOR SQUAD USE ONLY:
Criminal history record verified by State Police: Yes
□ No □ Date___ /___ /___ Sign____________Placed on file for 30 days ___ /___ /___
Accepted (90 Days Probation) ___ /___ /___
Rejected ___ /___ /___ List all reasons for rejection on an attached document
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