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 Country
Home Phone*
Work Phone
Cell Phone
Education and Training*
Use the + button on right to make additional entries.
Level Name/Location Dates Field/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 Held Date Issued – Date Expires State Issued From
Additional Experience
Please 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 Name Address Previous Position Dates 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 below
Professional References*
Please list 3 professional / work related references. Use the + button to the right to make additional entries.
Name Email Phone
Personal References*
Please list a minimum of one personal reference. Use the + button to the right to make additional entries.
Name Email Phone
Additional Information
Use this space to answer or clarify any previous questions, or to provide any additional pertinent information.
Medical Information
Please 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.
Name
This field is for validation purposes and should be left unchanged.

Level	Name/Location	Dates	Field/Diploma/Degree

Certifications or Licenses Held	Date Issued – Date Expires	State Issued From

Employer Name	Address	Previous Position	Dates Employed from (mm/yyyy)	Dates Employed to (mm/yyyy)	Phone Number

Name	Email	Phone

Application

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