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Submit Application

Name *

First

Last

Social Security Number *

Address *

City *

State *

Zip Code *

Contact Phone Number *

Email *

Reference 1 Name *

Reference 1 Contact Number *

Reference 2 Name *

Reference 2 Contact Number *

Reference 3 Name *

Reference 3 Contact Number *

Desired Status *

Senior Crew
Junior Crew
Support Crew
Employee

Senior Crew= 12 Hours/Week Junior Crew= Ages 15-18 Support Crew= 12 hours/Month

High School Gradutate? *

Name and Location of Highest Level of Education Completed *

Highest Level of Education Completed *

List all EMS, Fire Services, Police and/or Military Training (You will need to provide copies of completion/certification) *

May We Have Permission to Conduct a Character and Criminal Investigation on You? *

Yes
No

If No, Please Explain

Employee History #1 *

Name, Address, Start Date, End Date, Reason For Leaving

Employee History #2 *

Name, Address, Start Date, End Date, Reason For Leaving

Employee History #3 *

Name, Address, Start Date, End Date, Reason For Leaving

Have You Had Any Criminal Convictions? *

Yes
No

If Yes, Please Explain

Do You Have Any Physical, Medical, or Psychological Conditions That May Keep You From Performing Your Duties as a Member of an EMS Agency? *

Yes
No

If Yes, Please Explain

Do You Have a Valid Drivers License? *

Yes
No

Drivers License # *

WILL YOU READ AND COMPLY WITH THE BY-LAWS, THE STANDARD OPERATIONAL PROCEDURES OF THE CREW AND THE RULES AND REGULATIONS OF THE VIRGINIA DEPARTMENT OF HEALTH, OFFICE OF EMERGENCY MEDICAL SERVICES, REGIONAL AND LOCAL EMS SYSTEM? *

Yes
No

BY SUBMITTING THIS APPLICATION I AFFIRM THE INFORMATION IS ACCURATE AND CORRECT. IF THE INFORMATION ON THIS APPLICATION IS FOUND TO BE INCORRECT OR MISLEADING, YOU MAY BE DISMISSED FROM THE ORGANIZATION. *

I Agree
I Disagree

THE LEBANON LIFESAVING CREW INC. SHALL NOT DISCRIMINATE ON THE BASIS OF SEX, RACE, COLOR, RELIGION, SEXUAL ORIENTATION, OR NATIONAL ORIGIN.

Emergency Contact *

Name, Address, Phone Number, Relationship

Phone

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