Type of membership:
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PERSONAL DATA |
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Name (Last, Middle, First):
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Social Security #:
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Age:
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Date of Birth:
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Sex:
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Name preferred to be called:
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Marital Status:
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Address:
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How long have you lived at this address?:
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Home Phone:
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Cell Phone:
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Email Address:
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Driver License No.:
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State:
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License Class:
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License Experation Date:
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Any Physical Handicap:
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If yes describe:
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Any Serious Illness:
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If you have been convicted of a crime please describe:
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Have you ever served with this or any other EMS/Fire company before:
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If yes, when?:
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Name of EMS/Fire Company:
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Position:
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Training Level:
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Employment |
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Current Employer:
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Employer Address:
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Years at employer?:
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Job Title:
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Supervisor Name:
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Business Phone:
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Education |
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High School:
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High School Graduate?:
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Year Graduated:
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School City:
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School State:
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High School GPA:
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College:
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College Graduate?:
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Year Graduated College:
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College City:
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College State:
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College GPA:
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Trade Schools:
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REFERENCES |
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Reference #1 (Name, Address & Phone Number):
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Reference #2 (Name, Address & Phone Number):
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Reference #3 (Name, Address & Phone Number):
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EMERGENCY |
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In case of emergency, please notify:
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Emergency Contact Address:
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Emergency Contact Home Phone:
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Emergency Contact Work Phone:
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Emergency Contact Cell Phone:
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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.
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Application Submitted:
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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
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Membership Committee Chair |
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Invited to Membership Committee Date:
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By:
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Membership Committee Date:
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Committee Chairman:
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Board of Directors Meeting Date:
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Board of Directory : |
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Accepted
Rejected
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President Signature:
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Voted in for Active Membership Date:
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Voted in President Signature :
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*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.
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