Application Application Application Requirements*Please be aware that Rescue & EMS Public Safety work requires a very high level of attention to detail as well as the ability to document your work. This form is used as an evaluation of your ability to complete required documentation. The information requested in this application is the minimum needed information for us to began the process of considering your eligibility for employment and/or volunteer work with our agency. In order for your application to be considered all of the information requested on this form must be completed. Thank you,I have read and understand the above statement.Name* First Middle Last Date of Birth* MM DD YYYY Email* Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home Phone*Work PhoneCell PhoneEducation and Training*Use the + button on right to make additional entries.LevelName/LocationDatesField/Diploma/Degree Certifications and Licenses*CPR, Tech Rescue, EMT, EVD, RN, MD, etc. Use the + button on the right to make additional entries.Certifications or Licenses HeldDate Issued – Date ExpiresState Issued From Additional ExperiencePlease list/describe any special certifications, skills, or previous emergency experience that you have or extracurricular activities that you do that are relevant to your being a member of GCRS. For certifications, please include dates of expiration.I have five years of employment history?*YesNoEmployment History*List a minimum of five years, from most recent to least. Use the + button to the right to make additional entries.Employer NameAddressPrevious PositionDates Employed from (mm/yyyy)Dates Employed to (mm/yyyy)Phone Number May we contact your most recent employer?*YesNoIf you answered "no," please briefly explain belowWork References*Please list 3 work references. Use the + button to the right to make additional entries.NamePhoneAddressEmail Personal References*Please list a minimum of one personal reference. Use the + button to the right to make additional entries.NamePhoneAddressEmail Additional InformationUse this space to answer or clarify any previous questions, or to provide any additional pertinent information.Emergency Contact Info*NamePhoneAddressRelationship Medical InformationPlease list / describe any medical conditions (including medications) which may prevent or impair your ability to perform various tasks as a member of GCREMS or that we should be aware of in case of an emergency:Desired Position*Check all that apply Full Time - Career (Paid) Part Time - Career (Paid) EMS - Volunteer Rescue - Volunteer Resume or Certification(s) Drop files here or Accepted file types: pdf, jpg, png, doc, docx. Please upload electronic versions of any resume or certifications you may have.Signature*This is to certify that I, the above-signed, freely and voluntarily offers themselves to his fellow man regardless of race, creed, or color. It is to be clearly understood by this applicant that he/she is required to be available for call at any hour, day or night, providing that it does not interfere with his/her work or business. If the applicant is granted membership, he/she will be governed by the constitution and by-laws of this organization. The applicant’s signature on this application grants this organization permission to verify all information and conduct criminal background and DMV history reports. Any information being found falsified will be grounds for denial.NameThis field is for validation purposes and should be left unchanged.