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Rescue Membership Application

  1. CRS

  2. Colchester Rescue Membership Application

  3. 1. PERSONAL INFORMATION

  4. If different from street address.

  5. Do you have a valid driver's license?*

  6. Are you applying for:*

  7. Are you an active or past military member?*

  8. 2. EMPLOYMENT HISTORY

  9. If not employed enter n/a.

  10. Permission to contact employer?

  11. If none enter n/a.

  12. Permission to contact past employer?

  13. If none enter n/a.

  14. Permission to contact past employer?

  15. 3. EMS HISTORY

  16. Are you currently enrolled in an EMS licensure class?*

  17. Day Time (6 AM to 6 PM) Availability *

    Check all that apply

  18. Night Time (6 PM to 6 AM) Availability*

    Check all that apply

  19. 4. REFERENCES

  20. Please provide three references (not related to you) including name, occupation, and contact information (phone or email).

  21. Electronic Signature Agreement

  22. By electronically signing below you agree and acknowledge that:

    1. You authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature
    2. You may still be required to provide a traditional signature at a later date.
    3. The information provided is true and accurate to the best of your knowledge.
    4. You authorized the verfication of any or all of the information and any inquiries permissible by law to determine suitability for membership. Any intentional misrepresentation may lead to denial of membership.

  23. One upload per field.

  24. One upload per field.

  25. One upload per field.

  26. One upload per field.

  27. Leave This Blank:

  28. This field is not part of the form submission.