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 SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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?* Yes No Employment 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?* Yes No If you answered "no," please briefly explain belowWork / Employer References*Please list at least 1 references. Who you have worked for in the past that can give a work performance reference on you. You can use the + button to the right to make additional entries.NameEmailPhone Professional References*Please list at least 1 professional references. This person should not be a family relation to you. You can use the + button to the right to make additional entries.NameEmailPhone Personal References*Please list at least one personal reference. You can use the + button to the right to make additional entries.NameEmailPhone Additional InformationUse this space to answer or clarify any previous questions, or to provide any additional pertinent information.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 Select files Accepted file types: pdf, jpg, png, doc, docx, Max. file size: 128 MB. Please upload electronic versions of any resume or certifications you may have.Signature* Reset signature Signature locked. Reset to sign again 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.