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| Application Info |
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| Date/Time:
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04/24/2024 1037 |
| Type of Application: |
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New
Reinstatement from Inactive Membership
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| Check Membership Applying for: |
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Cadet (age 14 & 15)
Active (age 18 & up with EMT-B Certification or Higher)
Driver only (age 21 & up)
Reserve (COVID-19 Response)
Administrative (age 18 & up)
Provisional (age 16 & 17 with 1st Responder or higher; or age 18 or higher with EMR)
Associate (current member at another rescue/fire dept. in Tri-County with EMR or higher)
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| Personal Information |
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| First Name:
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| Middle Initial:
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| Last Name:
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| Date of Birth:
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| Social Security Number :
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| Address:
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| City:
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| State:
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| Zip:
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| Telephone:
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| E-mail Address:
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| Marital Status: |
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Single
Married
Widowed
Divorced
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| Additional Information |
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| Do you have a Driver's License?: |
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Yes
No
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| Number:
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| Class:
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| State Issued:
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| Have you ever been convicted or posted collateral/bail for any traffic violation: |
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Yes
No
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| If yes, list all such offences with date, place, and action taken:
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| Emergency Contact |
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| Contact Name:
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| Contact Relationship:
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| Contact Phone:
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| Background Information (A signed Volunteer Employment 'Consent/Release Form' by St. Mary's County Volunteer Emergency Services is required when this application is received and tabled at the meeting.) |
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| Have you ever been convicted of a misdemeanor or felony or are you under charge(s) for a misdemeanor or felony?: |
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Yes
No
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| If yes, list all offenses and state date, place and action taken:
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| Training (Please submit copies of any certifications you hold for any EMS/Fire Training and course work completed including dates of completion and/or expiration.) |
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| Please Include all training Including (Training Level) (MFRI / MIEMSS I.D. Number) (Completed or Expiration Date):
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| Please add copies of your certifications here:
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| Employment |
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| Are you currently employed : |
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Yes
No
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| Place of Employment:
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| ADDITIONAL RESCUE SQUAD/EMS/ALS/FIRE INFORMATION |
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| Are you a member of another Rescue Squad, EMS,ALS or Fire Department?: |
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Yes
No
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| Have you ever been a member of another RescueSquad, EMS, ALS or Fire Department?: |
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Yes
No
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| If yes, explain:
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| Attach a list of all Rescue Squad, EMS,ALS or Fire Department organizations to which you were either a paid and/or volunteer member. Include date (from/to), and any offices held:
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| Background Check Statement |
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| I understand that in order for my application to move forward and to be tabled I need to submit my Criminal Background Check Release Form: |
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Yes
No
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Please read carefully. By submitting this application for membership in the Mechanicsville Volunteer Rescue Squad, Inc., (MVRS), I authorize investigation of all statements contained therein. I hereby authorize MVRS to make any contacts considered necessary for me to become a member, such as current employers, criminal records, etc. It is understood and agreed that any misrepresentation by me in this application, will be sufficient cause for cancellation of the application or for separation from MVRS as a member at any time. I understand that this application is the property of Mechanicsville Volunteer Rescue Squad, Inc., and will become part of my personnel file if I am accepted as a member. Driver record checks may be required in accordance with MVRS insurance carrier's requirements. I hereby authorize MVRS to obtain my complete driving history. POLICY STATEMENT: MVRS is an equal opportunity organization and shall not discriminate against any member or applicant due to age, sex, marital status, national origin, religion, race, physical or mental handicap unrelated to the performance of the job or any other prohibited reasons. The Membership Committee will review this application and additional information developed during background checks. Applicants may be disqualified for criminal conduct. If applicant is less than 18 years of age, a parent or legal guardian MUST submit this application.
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