Application Date*

Last Name*

First Name*

Middle Initial

Address*

City*

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip*

Cell Phone*

Home Phone

Email*

Do you have a valid driver's license?*

Yes

No

Are you applying for *

Volunteer Member (18+) Jr. Volunteer Member (16-18 years)

Advertised Salaried Position

What is your Occupation? *

Current Employer (If none enter n/a)*

Date Range:

From:

to:

Supervisor's Name:

Supervisor's Phone

Supervisor's Email

Permission to contact Supervisor?

yes

No

Job Title/Responsibilities:

Past Employer (If none enter n/a)

Date Range:

From

to:

Supervisor's Name

Supervisor's Phone:

Supervisor's Email

Permission to call supervisor?

yes

no

Job Title/Responsibilities

Past Employer (If none enter n/a)

Date Range:

From:

to:

Supervisor's Name

Supervisor's phone:

Supervisor's Email:

Permission to call supervisor?

Yes

No

Job Title/Responsibilities

Education

Select High School College

Years Completed

Name of School, City, State*

Major

EMS License Level?

Select EMR EMT AEMT Paramedic CPR I do not have an EMS license.

Are you currently enrolled in an EMS licensure class?*

yes

no

Please describe any relevant training, education, licenses, and/or experience. If none, give work history and skills you would bring to EMS. *

If you have been or are currently a member of any EMS agencies please list the organization(s), city/state, phone number and dates of service.

Availability

Members are expected to run a regular 12 hour shift each week and at least one 12 hour weekend shift each month. Weekend shifts are scheduled for a volunteer's convenience. Day shift begins at 06:00h (6 AM) and ends at 18:00h (6 PM) NIght shift begins at 18:00h (6 PM) and ends at 06:00h (6 AM). Please indicate your availability to volunteer during the week.

Day Time Availability*

Monday Tuesday Wednesday Thursday

Friday Saturday Sunday None

Night Time Availability*

Sunday Monday Tuesday Wednesday

Thursday Friday Saturday None

Please describe your interest in Colchester Rescue and what drew you to this opportunity. *

Please provide three references (not related to you) including name, occupation, and contact information (phone or email)

Reference 1.

Name:*

Occupation:

Phone:

Email:

Reference 2.

Name:*

Occupation:

Phone:

Email

Reference 3.

Name:*

Occupation:

Phone:

EMail:*

Electronic Signature Agreement

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 requred to provide a traditional signature at a later date.
3. The information provided on this application is true and accurate to the best of your knowledge.
4. You authorize the verification of any or all of the information and any inquiries permissible by law to determine suitability for for membership. Any intentional misrepresentation may lead to denial of membership.

Electronic Signature*

If applicable, please attach any current EMS certification cards. Attach ONE file (PDF format) per upload field.

Attach File.

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

Attach File.

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

Attache file.

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

Optional: Attach Resume (PDF Format).

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)