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2. 
3. Colchester Rescue Membership / Employment Application
5. 1. PERSONAL INFORMATION
7. Today's Date*
   Today's Date
9. Last Name*
10. First Name*
11. Middle Initial
13. Street Address*
14. City
15. State*
17. Zip Code*
18. Mailing Address
    If different from street address.
20. Cell Phone Number*
21. Home Phone
22. Email Address*
24. Do you have a valid driver's license?*

    1. Yes
    2. No
25. Are you applying for:*

    1. Volunteer Membership (18+)
    2. Advertised Rescue Career Opening
    3. Per Diem AEMT/Paramedic
27. Education:*
    -- Select One --High School StudentHigh School GraduateSome College /College StudentCollege Graduate
28. Years Completed*
29. Name of current or last school attended:*
30. City and State
32. Are you an active or past military member?*

    1. Yes
    2. No
33. Branch
34. Dates From:
35. To:
37. Military training / experience relevant to Rescue membership.
39. 2. EMPLOYMENT HISTORY
41. Current Occupation*
    If not employed enter n/a.
42. Current employer
43. Dates From:
44. To:
46. Supervisor's Name
47. Supervisor's Phone
48. Supervisor's Email
50. Permission to contact employer?

    1. Yes
    2. No
51. Job Title and Responsibilities
53. Past Employer
    If none enter n/a.
54. Dates: From
55. To:
57. Supervisor's Name
58. Supervisor's Phone
59. Supervisor's Email
61. Permission to contact past employer?

    1. Yes
    2. No
62. Job Title and Responsibilities
64. Past Employer
    If none enter n/a.
65. Dates: From
66. To:
68. Supervisor's Name
69. Supervisor's Phone
70. Supervisor's Email
72. Permission to contact past employer?

    1. Yes
    2. No
73. Job Title and Responsibilities
75. 3. EMS HISTORY
77. EMS License Level*
    -- Select One --EMREMTAEMTParamedicCPRI do not have an EMS License
78. Are you currently enrolled in an EMS licensure class?*

    1. Yes
    2. No
79. If you have been or are currently a member of any EMS agencies please list the organizaitons, city/state, phone number and dates of service.
81. Day Time (6 AM to 6 PM) Availability *

    Check all that apply

    1. None
    2. Sunday
    3. Monday
    4. Tuesday

    1. Wednesday
    2. Thursday
    3. Friday
    4. Saturday
82. Night Time (6 PM to 6 AM) Availability*

    Check all that apply

    1. None
    2. Sunday
    3. Monday
    4. Tuesday

    1. Wednesday
    2. Thursday
    3. Friday
    4. Saturday
84. Describe your interest in Colchester Rescue and what drew you to this opportunity.*
86. 4. REFERENCES
88. Please provide three references (not related to you) including name, occupation, and contact information (phone or email).
90. Reference 1:*
91. Occupation
92. Phone
93. Email
95. Reference 2*
96. Occupation
97. Phone
98. Email
100. Reference 3*
101. Occupation
102. Phone
103. Email
105. Electronic Signature Agreement
107. By electronically signing below you agree and acknowledge that:
     1. You authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature
     2. You may still be required to provide a traditional signature at a later date.
     3. The information provided is true and accurate to the best of your knowledge.
     4. You authorized the verfication of any or all of the information and any inquiries permissible by law to determine suitability for membership. Any intentional misrepresentation may lead to denial of membership.
109. Electronic Signature*
111. If applicable, please attach current EMS certification cards.
     One upload per field.
112. Upload certification.
     One upload per field.
113. Upload Certification
     One upload per field.
115. Optional: Attach Resume
     One upload per field.
Leave This Blank:


117. 1. Receive an email copy of this form.
118. Email address

     This field is not part of the form submission.

119. Submit Submit and Print

* indicates a required field