Membership Application - St. Mary's County Advanced Life Support

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Membership Application

Indicates Required Field


Identification Info:

Full Name (Last, First, Middle):
Email Address:
Address:
City, State Zip:
Date of Birth:
Cell Phone:
Home Phone:
Work Phone:

Drivers License Info:

Drivers License Number:
Issuing State :
Class:
Restrictions:

Type of membership applying for:

Type of membership you are applying for?:

Current Level of Training:

Please list all certification and include any license numbers and expiration dates:

Current Affiliation:

Please list all other EMS affiliations (Current and Past). Include Department name and dates of service.:

Medical Conditions

Is there anything that may inhibit, or prohibit you from performing emergency care duties?:
If yes to previous question, please explain:

Criminal Past

Have you ever been convicted of a crime other than a traffic violation?::
If yes, please explain:

2 Personal References

Reference 1 - Name:
Reference 1 - Phone:
Reference 1 - Relationship:
Reference 2 - Name:
Reference 2 - Phone:
Reference 2 - Relationship:

Emergency Contact

Please enter the name and phone number of one (1) person to be contacted in case of emergency:
Date Submitted:		04/25/2024 1647

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www.FirehouseSolutions.com	St. Mary's County Advanced Life Support P.O. Box 2421 Leonardtown, MD 20650	Emergency Dial 911 Non-Emergency: 301-690-2044 E-mail: info@smcals.org