Federal and State law requires that all applicants be considered without regard to race, color, creed, sex, age, religion or national origin, marital status, sexual orientation, political or religious opinion or affiliations, and physical or mental handicap (except in such cases where the disability or condition would preclude the individual from adequately performing the task involved).

We believe in and fully support equal employment opportunity and will fulfill our obligation to the fullest.

Indicates Required Field

Type of membership:		Select Below Auxiliary EMT Driver Fire Other
PERSONAL DATA
Name (Last, Middle, First):
Social Security #:
Age:
Date of Birth:
Sex:		Select Below Male Female
Name preferred to be called:
Marital Status:		Select Below Single Married Divorced Widowed
Address:
How long have you lived at this address?:
Home Phone:
Cell Phone:
Email Address:
Driver License No.:
State:		Select Below Alabama - AL Alaska - AK Arizona - AZ Arkansas - AR California - CA Colorado - CO Connecticut - CT Delaware - DE Florida - FL Georgia - GA Hawaii - HI Idaho - ID Illinois - IL Indiana - IN Iowa - IA Kansas - KS Kentucky - KY Louisiana - LA Maine - ME Maryland - MD Massachusetts - MA Michigan - MI Minnesota - MN Mississippi - MS Missouri - MO Montana - MT Nebraska - NE Nevada - NV New Hampshire - NH New Jersey - NJ New Mexico - NM New York - NY North Carolina - NC North Dakota - ND Ohio - OH Oklahoma - OK Oregon - OR Pennsylvania - PA Rhode Island - RI South Carolina - SC South Dakota - SD Tennessee - TN Texas - TX Utah - UT Vermont - VT Virginia - VA Washington - WA West Virginia - WV Wisconsin - WI Wyoming - WY
License Class:
License Experation Date:
Any Physical Handicap:		Select Below Yes No
If yes describe:
Any Serious Illness:		Select Below Yes No
If you have been convicted of a crime please describe:
Have you ever served with this or any other EMS/Fire company before:		Select Below Yes No
If yes, when?:
Name of EMS/Fire Company:
Position:
Training Level:
Employment
Current Employer:
Employer Address:
Years at employer?:
Job Title:
Supervisor Name:
Business Phone:
Education
High School:
High School Graduate?:		Select Below Yes No
Year Graduated:
School City:
School State:		Select Below Alabama - AL Alaska - AK Arizona - AZ Arkansas - AR California - CA Colorado - CO Connecticut - CT Delaware - DE Florida - FL Georgia - GA Hawaii - HI Idaho - ID Illinois - IL Indiana - IN Iowa - IA Kansas - KS Kentucky - KY Louisiana - LA Maine - ME Maryland - MD Massachusetts - MA Michigan - MI Minnesota - MN Mississippi - MS Missouri - MO Montana - MT Nebraska - NE Nevada - NV New Hampshire - NH New Jersey - NJ New Mexico - NM New York - NY North Carolina - NC North Dakota - ND Ohio - OH Oklahoma - OK Oregon - OR Pennsylvania - PA Rhode Island - RI South Carolina - SC South Dakota - SD Tennessee - TN Texas - TX Utah - UT Vermont - VT Virginia - VA Washington - WA West Virginia - WV Wisconsin - WI Wyoming - WY
High School GPA:
College:
College Graduate?:		Select Below Yes No
Year Graduated College:
College City:
College State:		Select Below Alabama - AL Alaska - AK Arizona - AZ Arkansas - AR California - CA Colorado - CO Connecticut - CT Delaware - DE Florida - FL Georgia - GA Hawaii - HI Idaho - ID Illinois - IL Indiana - IN Iowa - IA Kansas - KS Kentucky - KY Louisiana - LA Maine - ME Maryland - MD Massachusetts - MA Michigan - MI Minnesota - MN Mississippi - MS Missouri - MO Montana - MT Nebraska - NE Nevada - NV New Hampshire - NH New Jersey - NJ New Mexico - NM New York - NY North Carolina - NC North Dakota - ND Ohio - OH Oklahoma - OK Oregon - OR Pennsylvania - PA Rhode Island - RI South Carolina - SC South Dakota - SD Tennessee - TN Texas - TX Utah - UT Vermont - VT Virginia - VA Washington - WA West Virginia - WV Wisconsin - WI Wyoming - WY
College GPA:
Trade Schools:
REFERENCES
Reference #1 (Name, Address & Phone Number):
Reference #2 (Name, Address & Phone Number):
Reference #3 (Name, Address & Phone Number):
EMERGENCY
In case of emergency, please notify:
Emergency Contact Address:
Emergency Contact Home Phone:
Emergency Contact Work Phone:
Emergency Contact Cell Phone:
Electronic Signature: In submitting this application, I authorize investigation of all statements contained herein inclusive of a Criminal Background Check (18 years of age and older). I hereby authorize the Dentsville Volunteer EMS and Auxiliary, Inc. to make any contacts considered necessary to any person or organization listed on this application to release said information. I understand any misrepresentation by me in this application is sufficient cause for cancellation of this application.
Application Submitted:		06/04/2023 2253
Parent or legal guardian Electronic signature: If applicant is under 18 years of age, a parent or legal guardian must sign application
Membership Committee Chair
Invited to Membership Committee Date:
By:
Membership Committee Date:
Committee Chairman:
Board of Directors Meeting Date:
Board of Directory :		Accepted Rejected
President Signature:
Voted in for Active Membership Date:
Voted in President Signature :
*This application must be submitted prior to our regular Membership Committee Meeting, held the last Thursday of each month at 7:00 p.m. If you cannot attend this meeting you must notify the Membership Committee Chairman @ (301) 392-0050.