KPFARS Application – Kendall Park First Aid and Rescue Squad

Membership Application

Name

First

Last

Address

Address Line 1

City

State

Zip Code

you years? of

Phone

Email

Driver's License # and State

Social Security #

Previous Training

Current Certifications (Check all that apply)

Previous EMS affiliation (Specify)

Employment

Occupation

Employer

Telephone #

Street Address

City, State

ZIP

Legal

Has your Driver's License been revoked or suspended within the past 3 years?

Yes
No
Do not have a License

Have you ever been convicted of a crime?

Yes
No

(If you answered "Yes" to either of the above questions, please explain below).

References

Name 1

First

Last

Phone

Address

Address Line 1

City

State

Zip Code

Name 2

First

Last

Phone

Address

Address Line 1

City

State

Zip Code

Name 3

First

Last

Phone

Address

Address Line 1

City

State

Zip Code

You may attach a file here if needed. No larger than 10Meg.

Drag & Drop Files, Choose Files to Upload

Signature/Date

I hereby certify that the statements made in this application are true to the best of my knowledge and belief. I understand that any intentionally false statement may be grounds for rejection of this application or termination of membership in the Kendall Park First Aid & Rescue Squad. I also understand that the Kendall Park First Aid & Rescue Squad will obtain an abstract of my motor vehicle record and I authorize such for the purposes of this application.

Date / Time

Date

Time

Enter your name as a temporary signature.