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

Name 

Street Address

Mailing Address (if different)

City, State, Zip

Email:

Years at this location

If under 18 years old date of birth (mm/dd/yyyy)

Phone number HomeCell

Driver License State NumberExpiration date (mm/dd/yyyy)

 Emergency contact Name, address, phone

High School attended  AddressYear graduated

College or trade school attended AddressYear graduated

Present employmentEmployer address & phone number

Working hours   Length of employment

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? Yes No

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.