PPFAS Application for Membership

PPFAS Application for Membership

This application will take about 15 minutes to complete.
Personal Info
Name*

First NameLast Name
Nickname
Date of Birth*

MonthDayYear
Social Security Number*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Are you related to a squad member?*

YesNo
Where did you hear about us?
Are you, or have you ever been, affiliated with another First Aid Squad? Please specify. *
What is your current availability? Please be detailed.*
Have you ever been indicted, or entered a plea of guilty to an accusation for an indictable offense? If yes, was there a conviction by a plea of guilty, or such finding by a jury?*
Emergency Services Background
Certification History*

CPREMTCEVOFirefighterHAZMATExtricationNONEOther
CPR Cert Expiration

MonthDayYear
If applicable
EMT Cert Expiration

MonthDayYear
If applicable
Certifications

Please upload copies of ALL your selected certifications.
Cancelof
Drivers License Info
State*
License Number*
Drivers License*

Please upload the front AND back of your license.
Cancelof
Do you have any points?*

NoYes
Have you been in any accidents?*

NoYes
Education
High School
Please specify city.
High School Graduation Year
College
Please specify city.
College Graduation Year
Employment
Employer*
Phone Number
Title*
Your title at your job.
May we contact?*

YesNo
References

Please provide three references, that are not immediate family.
Reference 1 Name*
Phone Number*
Please enter a valid phone number.
Relationship to you*
Reference 2 Name*
Phone Number*
Please enter a valid phone number.
Relationship to you*
Reference 3 Name*
Phone Number*
Please enter a valid phone number.
Relationship to you*
Application Declaration
By signing below, I agree that if accepted under this application, I agree to comply with all orders, rules, regulations and duties of the squad. I further agree that I am of sound mind and body, and will submit to a written physiological examination and a physical examination to be performed by the squads’ physician and/or line officers. By signing and submitting this application I give consent to the Pleasant Plains First Aid Squad to perform a routine police background check, substance use test, and motor vehicle check prior to my acceptance and check on at random. I will provide details of any changes during my time with the squad. The answers to the forgoing are true to the best of my ability belief and knowledge. It is understood that any false statement on this application is sufficient cause for immediate rejection or dismissal.
Name*
Todays Date*

MonthDayYear
Signature*

Clear
Please verify that you are human*
Should be Empty:

PPFAS Application for Membership

Personal Info

Emergency Services Background

Drivers License Info

Education

Employment

References

Application Declaration