APPLICATION FOR MEMBERSHIP TO THE:
BOLTON EMERGENCY MEDICAL SERVICES, INCORPORATED
Bolton Emergency Medical Services, Incorporated accepts applications for
membership regardless of an applicant’s race, color, creed, sex, marital
status, disability, national origin or place of birth.
Application for: Volunteer Position
or Paid Position
Mailing Address (if different)
City, State, Zip
Years at this location
If under 18 years old date of birth (mm/dd/yyyy)
Phone number HomeCell
Driver License State NumberExpiration
Emergency contact Name, address, phone
High School attended AddressYear
College or trade school attended
address & phone number
Working hours Length of
List other employers in the past 3 years
Please list 3 general references with contact information
Bolton EMS reference (if known)
Have you ever been convicted of a crime or are you currently
awaiting charges on any crime including traffic tickets?Yes*No
*If yes to the above question please explain
Have you ever been a member of a Fire Department or Emergency Squad before?
If yes name of agency & duties performed
Please list any special training, qualifications or skills
I hereby apply for membership in Bolton Emergency Medical Services,
Incorporated. I understand that my acceptance in the corporation will be on a
six month probationary basis during which time my membership may be terminated
in accordance with the corporate by-laws. Any false statements or omissions
made in this application will be considered sufficient cause for expulsion
from the corporation upon discovery thereof.
I hereby authorize Bolton Emergency Medical Services, Incorporated or its
representatives to make official inquiry of all persons, schools, public and
private companies, corporations, consumer reporting agencies, law enforcement
agencies, state licensing and certifying agencies and medical advisors of this
corporation to supply all information concerning my character, current and
prior employment or membership verification, general reputation, personal
characteristics and mode of living, and furnish reports thereon.
If accepted into membership into Bolton Emergency Medical Services,
Incorporated, I will follow the operating rules as adopted and the by-laws as
they may be amended in the future. I will agree to submit to physical and
medical examinations at the option and expense of Bolton Emergency Medical
Services, Incorporated and also agree that the examining physician will
disclose to the representatives of Bolton Emergency Medical Services,
Incorporated the results of such examinations.
By clicking on the submit button I hereby certify that the above information
is complete and correct to the best of my knowledge.