Fremont Rescue and EMS, Inc.
Membership Application
Name  
 Middle Name
 Last Name:  
Age  
 Date of birth
 SS Number
 Drivers License No.
Address:  
 City
 Zip Code
Home Phone  
 Cell Phone No.  
 Work Phone
Email Address:   
Place of Employment  
 Phone No.
 How long?
Type of Certification Held
 Date of Certification
Describe any special training or skills you have that you could contribute to the Squad     
Are you able to lift 60 pounds?
 
 Yes
 No
 Are you able to attend training at least
once a month?
 Yes
 No
Will you be able to pull 3 nights
per month of call time?
 Yes
 No
 Will you be able to spend the night at
the building while on call?
 Yes
 No
Have you ever been convicted of a crime?  Misdemeanor or Felony?
(including traffic offenses)   
 Yes
 No
If yes, explain
Please list 3 references (Do not include family)
Name                                 Address                                             Phone    
1.
2.
3.
Emergency Contact Person:
 Name  
 Phone Number
(I state that the above information is true to the best of my knowledge).  I understand that falsifying
information or giving untrue statements is grounds for my application to be rejected or grounds for
dismissal from the squad.
Signature (Electronic):      
Date