Join Us – CCMICU-60

Membership Application

Membership Application Form

Personal Information
Background Information
References
Consent

Section I - Personal Information

All fields marked with an asterisk are mandatory. You will not be able to move to the next section or, complete and submit the form without populating these fields.

Interested in becoming?

First Name

Last Name

Date of birth

Social Security Number (SSN)

Address

Address 1

Address 2

City

State

Zip Code

Country

Telephone #

Driver's License #

Has your driver's license ever been suspended or revoked?

Current Points

How many accidents have you had within the past 3 years?

If you have more than 5 points OR, your drivers license has been suspended/revoked please explain below. Give all dates and resolutions

Emergency Contacts

Please provide the name of an emergency contact. If you would like to provide a second contact, please select "YES" from the dropdown menu.

First Name

Last Name

Telephone #

Would you like to provide a second emergency contact?

First Name

Last Name

Telephone #

Section II - Background Information

Have you ever applied to this department before?

Have you ever been suspended or dismissed from an EMS/Fire company?

Date of Application?

If YES, please provide the date of suspension or dismissal

You answered YES to the above question, please provide details

Have you ever been convicted of a felony or misdemeanour?

If you answered YES to this question, please explain.

Please list all Fire/EMS departments (with dates), you have been a member at in the last 10 years. Include contact information and current status with that department

Section III - References

List as character references two people you have known for at least two years who are not related to you.

First Name

Last Name

Telephone #

First Name

Last Name

Telephone #

Section IV - Consent

I authorize the investigation of all statements made herein. I certify the information provided in this application is complete and correct to the best of my knowledge. I understand any false statements or omissions of information requested may be just cause for denial of this application, or dismissal from this organization without recourse. Information will be verified through, but not limited to: MD Judiciary, MD Motor Vehicle Association, MIEMSS Compliance Department, NREMT Compliance, Past Department Leadership.

I agree to the consent statement as outlined above.

I Agree

Signature

Please upload valid photo ID; drivers license preferred

Choose File(s)

Please upload any current certifications i.e. CPR, EMT, ICS, etc.

Choose File(s)

Membership Application

Section I - Personal Information

Emergency Contacts

Section II - Background Information

Section III - References

Section IV - Consent

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