Clement Rescue & EMS Inc. Membership Application

Thank you for your interest in Clement Rescue & EMS Inc. Please submit the following information and submit your application. Each submitted application will be reviewed at our meetings held the 1st and 3rd Tuesdays of each month.

* First Name

* Middle Initial

* Last Name

* Street Address

* City

* State

* Zip

* Home Phone

* Work Phone

* Email Address

* Social Security Number

* Years Experience in EMS

* Drivers License Number

* State Certification

* Experation Date

* Additional Certifications

Please make copies of all certification cards. If possible supply experation dates for each certification in the additional information box below.

*

Are you available to pull call at night and on weekends?

Yes

No

* What nights are you available to pull calls?

* 1st References - Name, Address & Contact Number

* 2nd References - Name, Address & Contact Number

* 3rd References - Name, Address & Contact Number

Additional Information You Feel May Be Important

* Do We Have Your Permission to do a driver license check and contact references for a background check?

Yes

No

* Indicates Response Required