Newington EMS Application

First name

Last name

Email that you regularly check

Phone

Primary phone number to contact you

Date of Birth

Month

Day

Year

Address

Note: You do not need to be a resident of Newington to be a member

Driver's License State Issuer and Number

For Example: CT 123456789

Current Employment Status

Employed

Unemployed

Student

Other

Present Employer

May we contact your present employer?

Yes

Do you have any disabilities that may prevent you from performing any of the duties of an EMT?

If answered yes, please explain

Have you ever been convicted of a crime?

If answered yes, please explain

References

Please list three references. Full name, title, relationship, and phone number. By providing these references, you give permission for Newington EMS to contact and ask about your character and past work experience

Do you have any relevant EMS experience?

Volunteer/paid EMS service, hospital tech, etc

Current EMS Certifcation Level

State Certification Number

NREMT Certification Number

Do you hold a valid American Heart Association BLS Card (CPR/AED)?

Do you possess any additional relevant certifications?

List the title and number of any additonal certifications such as CEVO, EVOC, NIMS, and etc.

How did you hear about us?

If a NEMS member referred you, please enter the name of the member

I certify that all the above information is true to the best of my knowledge. I understand that omissions and misrepresentations in this application are grounds for rejection and immediate dismissal by the membership board. By clicking this box, you understand that your application may be rejected for any reason by NEMS.

Signature

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