EMS Chief Application

Legal Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Residential Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Start Date *

MM

DD

YYYY

End Date

MM

DD

YYYY

Most Recent Employer Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Most Recent Employer Supervisor/Manager *

First Name

Last Name

Most Recent Supervisor/Manager Phone Number *

(###)

###

####

Are you able to lift a minimum of 50lbs? *

Yes

No

Have you been convicted of a crime? *

Yes

No

Any pending criminal charges? *

Yes

No

Any traffic violations in the last 3 years? *

Yes

No

Any DUI/OWI violations in the last 7 years? *

Yes

No

Any driving license suspension, revocation, or restrictions in the last 7 years? *

Yes

No

Any EMS license suspension, revocation, or restrictions in the last 7 years? *

Yes

No

Electronic Signature *

By clicking the 'I Agree' button below, you agree and understand that your electronic signature on this document is legally equivalent to your handwritten signature, and you consent to be bound by the terms of this agreement. You acknowledge that you have the right to request a paper copy of this document, and any other electronic records related to this agreement. You also understand that you may withdraw your consent to receive electronic records at any time, and that doing so will not affect your rights or obligations under this agreement.

First Name

Last Name

E-Signature Consent *

I Agree

I Disagree