APPLICATION
FOR MEMBERSHIP
HVRS
-
NAME: _______________________________________
PREFERRED NAME:___________________
ADDRESS:_____________________________________
CITY/STATE:______________ ZIP:________
HOME PHONE:(__)____-_____
WORK PHONE:(__)____-_____
SOCIAL SECURITY NUMBER:_______________________
DATE OF BIRTH: Month_______Day
____Year _____
EMPLOYER:__________________________________________________________
ADDRESS: ___________________________
CITY/STATE___________ ZIP_____
Do you have a valid driver's license? ____Yes
____No
Have you been convicted of a: Felony __Yes
__No Misdemeanor __Yes __No
If Yes, please
explain and give date___________________________________
________________________________________________________________________
Education Level (Circle last year completed)
Grade 5 6 7 8 High School 9 10 11 12 College
1 2 3 4 Graduate 1 2 3 4 5
Please list any other technical/professional
degrees:
________________________________________________________________________
Please list the following for each EMS Agency
to which you have previously
belonged or been a member: (lncluding
any within the
Agency:_____________________________________________
Position:________________________________
Date of Experience_______________
Agency/Dept. Supervisor:_________________________________________
Agency:______________________________________________
Position:________________________________
Date of Experience_______________
Special Training or Certifications
received:__________________________________________________________________
PLEASE LIST ANY OTHER PROFESSIONAL OR
VOLUNTEER EXPERIENCE
WHICH MAY BE HELPFUL IN YOUR POSITION AS
VOLUNTEER
PROVIDER:_________________________________________________________________
Special training, skills, or Interests:___________________________________
Restrictions that might/will affect your
availability for volunteer work
( family, work schedules, medical restrictions,
etc._______________________
In case of emergency, notify?____________________________________________________
Name Address City/State Zip,
Relationship:______________________
Phone:___________________
Physician: ________________________ Phone:___________________
Please attach copies of the following to this
application:
* DMV Driving Record
* Copies of any pertinent EMS Certifications
Please provide the following information for
3 people who can attest to your
qualifications and interest as a Volunteer EMS provider:
Name:_______________________________________
Address:____________________________________
City/Stat:_________________________
Zip Code:____________________
Home Phone:________________________
Work Phone:__________________
Name:_______________________________________
Address:____________________________________
City/Stat:_________________________
Zip Code:____________________
Home Phone:________________________
Work Phone:__________________
Name:_______________________________________
Address:____________________________________
City/Stat:_________________________
Zip Code:____________________
Home Phone:________________________
Work Phone:__________________
By signing this application for membership, I
hereby agree that the information provided is complete and accurate. I further
understand that by providing this information, I agree that the agency may
verify the information received in evaluation of any application. I understand
that any willful mistatements or material omission on
this application will be considered sufficient cause to disqualify my
application
Senior Membership __________
Junior Membership __________
Signature: ________________________ Date:
__________________
Please return to HVRS Attn: Membership