REMS Team Application | Fireline Medics

Rapid Extraction Module Support Teams Application
Personal Information
Name*

First NamePreferred First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth(Required)
Email(Required)*
Home Airport(Required)
Secondary Airport(Required)
Shirt Size(Required)
Are you Currently Working?(Required)

YesNo
Please specify your availability to deploy for a minimum of 14 days on 48-72 hour notice.
You have worked with Fireline Medics LLC in the past?(Required)

YesNo
If Yes, please provide dates
Experience as a Wildland Firefighter(Required)
Experience on a REMS team(Required)
Veteran Status(Required)

YesNo
Certifications
State Certifications

EMTAEMTParamedic
State License Number
Copy of State License

Cancelof
Red Card

YesNo
If Yes, Please include your Red Card Number
Copy of Red card

Cancelof
National Certification*

EMTAEMTParamedicN/A
If you have national registry, Please include your National License Number
Copy of National Registry

Cancelof
I also have the folowing Certifications:

Introduction to ICS (I-100)NIMS: and Introduction (IS-700)Firefighter Training (S-130)Introduction to Wildland Fire (S-190)Human Factors in the Wildland Fire Service (L-180)Annual Fireline Safety Refresher (RT-130) (For current year)Arduous Work Capacity Fitness Test (Pack Test)Other
Fire Certifications upload

Cancelof
Rescue Certifications

Swift Water RescueRope Rescue AwarenessRope Rescue OperationsRope Rescue TechnicianConfined Space OperationsConfined Space TechnicianExtrication TechnicianExtrication OperationsOther relevant Certifications/Certificates
Rescue Certifications

Cancelof
Education
Education:(Required)*

High SchoolG.E.DCollegeTrade SchoolNone of the Above
Institution Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Previous Employment
Name of Company
From

MonthDayYear
Date
To

MonthDayYear
Date
Position
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Supervisor Name

First NameLast Name
May we contact this company/supervisor?*
May we contact this company/supervisor?
May we contact this company/supervisor?
If there is a 6+ month gap between employment positions, please explain why:
Please briefly explain your connection to this person (Are they a Personal or Professional Reference)?
Please briefly explain your connection to this person (Are they a Personal or Professional Reference)?
Please briefly explain your connection to this person (Are they a Personal or Professional Reference)?
Signature*

Clear
Should be Empty:

Rapid Extraction Module Support Teams Application

Personal Information

Certifications

Education

Previous Employment