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| Application Info |
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| Date/Time:
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11/14/2024 1903 |
| Type of Application: |
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New
Reinstatement from Inactive Membership
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| Check Membership Applying for: |
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Regular Membership
Associate Membership
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| Personal Information |
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| First Name:
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| Middle Name:
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| Last Name:
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| Date of Birth:
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| Social Security Number :
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| Address:
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| City:
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| State:
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| Zip:
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| Telephone:
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E-mail Address:
Please check this email account regularly for pertinent information sent to you by the Investigating Committee
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| Marital Status: |
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Single
Married
Widowed
Divorced
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| Additional Information |
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| Do you have a Driver's License?: |
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Yes
No
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| Have you ever been convicted or posted collateral/bail for any traffic violation: |
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Yes
No
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| If yes, list all such offences with date, place, and action taken:
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| Emergency Contact |
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| Contact Name:
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| Contact Relationship:
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| Contact Phone:
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| Background Information |
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| Have you ever been convicted of a misdemeanor or felony or are you under charge(s) for a misdemeanor or felony?: |
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Yes
No
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| If yes, list all offenses and state date, place and action taken:
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| Do you have any pre-existing medical conditions that would prevent you from safely performing the duties of an emergency medical technician/emergency medical responder? : |
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No
Yes
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| If you do have any pre-existing medical conditions, please explain:
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| Have you ever had any healthcare certification or license withheld, suspended, revoked, denied, or have you surrendered, or allowed a license or certificate to expire or lapse as the result of an investigation or disciplinary action: |
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No
Yes
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| If you have had healthcare certification withheld, suspended, revoked, denied, or have you surrendered, or allowed a license or certificate to expire or lapse, please explain :
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| Training (Please list any certifications you hold for any EMS/Fire Training and course work completed including dates of completion and/or expiration.) |
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| List of EMS/Fire Training and Certifications:
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| Employment |
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| Are you currently employed : |
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Yes
No
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| Place of Employment:
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| Position:
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| Supervisor's Name:
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| Telephone:
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| May we contact your employer?:
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Yes
No
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| If no, please explain:
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If less than five (5) years with present employer, give past employer information:
Name of Employer
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| Date Hired:
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| Date and Reason for Leaving:
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| Position Held:
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| Previous Supervisor's Name:
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| ADDITIONAL EMS/FIRE/RESCUE SQUAD INFORMATION |
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Are you a member of another volunteer EMS or Fire Department:
If yes, what company do you volunteer with?
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| Have you ever been a member of another volunteer Fire or EMS Department: |
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Yes
No
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| If yes, explain:
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| List all Fire or EMS organizations to which you were either a Paid and/or Volunteer member. Include date (from/to), and any offices held:
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| Have you ever been barred from, or refused membership in any other volunteer Fire or EMS company: |
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No
Yes
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| If you have been been barred from, or refused membership in any other volunteer Fire or EMS company, please explain:
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| Why do you want to be a member of our organization :
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List three Business, Professional or Personal References:
Include Name, Phone #, How long known, and Type of Relationship for 3 business, professional, or personal references
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| Background Check Statement |
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| I understand that in order for my application to move forward and to be tabled I need to submit my Criminal Background Check Release Form: |
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Yes
No
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I authorize the Havre de Grace Ambulance Corps Investigation Committee and the Board of Directors and its agents to investigate all statements contained in the application, to investigate my background, and obtain information concerning my qualifications as a prospective member. In conjunction with this investigation, I authorize any fire, rescue, or ambulance company where I have been affiliated to give the company any and all information they have regarding my performance and capabilities for the position I have applied for. I also authorize the Havre de Grace Ambulance Corps to release such information as necessary to those members or agents of the company who require such information to investigate or to make a decision with respect to any matter pertaining to my membership. I am aware that a background investigation can lead to the rejection of my application for membership and I absolve any member of the Havre de Grace Ambulance Corps, Inc., from any civil action on my part which may result from said rejection.
I certify the information contained in this membership application is true, complete, and correct to the best of my knowledge. I understand that any misstatements or omissions in this application may result in the company refusing to accept me as a member, or if granted membership, in the immediate termination of my affiliation to the Havre de Grace Ambulance Corps, Inc.
I agree to pay the $10.00 application fee to the Investigating Committee Chair when I arrive for my scheduled interview.
If I am accepted, I agree to abide by the By-laws, Standard Operating Procedures, and the Policies outlined in the Member Handbook of the Havre de Grace Ambulance Corps, Inc.
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