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Application for Rescue Squad Membership

Rescue Squad

Applicant's Information

Last First Middle

Social Security Number

Address City State

Zip Code Gender Race Date of Birth

Home Phone Work Phone Cell Phone

Driver's Liscense Number

Date Joined Rescue Squad

Certification Level

MR EMT-B EMT-1 EMT-P

Member MICN

Re-certification Date

Next of Kin Information

Name Relation

Address City State

Zip Code

Phone Number 1 Phone Number 2

Submit Application

IMPORTANT: To assure our data is accurate and to properrly enroll you with Workers' Compensation and the States Inline Duty Death Benefit, all blanks must be completed before this application will be accepted in the Emergency Services Office

When you submit an application the original must be mailed or delivered to the Emergency Services Office within 30 days