Pembroke Rescue Squad Employment Application

Position Applying For

Name*

First NameLast Name

Birth Date

MonthDayYear

Phone Number*

Email

example@example.com

Address*

Street Address

Mailing Address

CityState / Province

Postal / Zip Code

How were you referred to us?*

Do you currently hold a valid NC EMS or TR Certification

YesNo

Upload Certifications and Driver's License

P-Number

References

Please list two (2) references that are familiar with your work life.

Reference

Past or Current Employer

Have you been convicted or have any pending criminal charges. *

Include DWI or Major Traffic Offences

Are you willing to Volunteer when required?*

Please give a brief explanation of why you want to be a team member at Pembroke Rescue Squad. You may include any additional information that you would like to share with us.

Emergency Contact

Signature*

I hereby affirm that the above information is true and correct to the best of my knowledge. I also realize that any fraudulent information may be sufficient cause or subsequently revocation of my membership. I further affirm that I have never been convicted of a felony or sex crime. Finally, I affirm I have not been convicted of any felony under the laws of the United States of America with in the last five years. It is understood that if I am accepted, I shall be required to abide by the rules and regulations set forth in the By-Laws of the Pembroke Rescue Squad also all state and local laws and guidelines or be subjected to dismissal by Pembroke Rescue Squad Inc. I authorize investigation of my character references, driving records, physical and mental conditions, criminal background or any other matter contained on this application.