EmailMe Form - Stafford Township Emergency Medical Services

Applying For: *

Name *

First Middle Last

Date of Birth *

xx/xx/xxxx

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Email *

Phone (Cell Preferred) *

### - ### - ####

Phone Type *

Social Security # *

Driver's License #

Issuing State

Expiration Date

MM / DD / YYYY

How Long Have You Been Driving?

If applicable, please upload a copy
of your driver's license

Have You Ever Been in an Accident? *

YES

NO

If yes, please explain:

Have You Ever Been
Convicted of a Crime? *

YES

NO

If yes, please explain:

Employment

Employer's Name *

If not employed, please enter "NOT EMPLOYED"

Employer's Phone #

### - ### - ####

Employer's Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Do You Have Any
Physical Limitations? *

YES

NO

If yes, please explain:

EMS Experience

(previous experience is not necessary)

Have you ever been a member
of any other Fire/EMS agency? *

YES

NO

If yes, what was the name of the organization and the dates you were active?

Who can we speak to in that organization about your experience?

What is their phone number?

### - ### - ####

Do you hold a valid CPR Certification? *

YES

NO

If selected YES to a valid CPR Cert,
please enter the expiration date below

Example: xx/xxxx

Do you hold a valid EMT Certification? *

YES - New Jersey

YES - National Registry

NO

If selected YES to a valid EMT Cert,
please enter the expiration date below

Example: xx/xxxx

If yes, please upload copy of CPR card

If yes, please upload copy of EMT card

List any other first aid courses attended:

Availability

Please select the days and times you are available. This will make it easier to decipher your placement on crews.

Days Available *

Times Available *

12am to 6am

6am to 12pm

12pm to 6 pm

6pm to 12am

I hereby attest that all of the above information is true to the best of my knowledge
and agree to any personal screening of my background and driving record through
local, state, and federal authorities. I authorize the Stafford Township Emergency
Medical Services to complete this background investigation. I agree that if any of the
above information is found to be false, my application will be terminated immediately
with no chance to reapply. I understand that Stafford Township Emergency Medical
Services has the authority to investigate and accept or reject any or all statements
presented above.