Membership Application

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Email *

Type of Membership *

Cadet

EMS Member

Rescue Associate

Support Member

Required

First and Last Name *

Date of Birth *

YYYY

Address (Street, City, Zip) *

Occupation

Primary Phone Number *

Secondary Phone Number

Do you have a valid Driver's License *

Yes

Driver's License Number

Has your driving privilege ever been revoked or suspended? *

Yes

I have no Driver's License

If yes, please explain with court, date of incident, and penalty.

Have you ever been arrested? *

Yes

If yes, please explain with date, location, and reason for the arrest.

Have you ever been convicted or entered a plea of guilty to a crime other than a motor vehicle violation? *

Yes

If yes, please explain with court, date, and settlement of the court.

Would you be willing to submit to a police background check? *

Yes

Do you have any first aid, rescue, or medical training? *

Yes

If yes, please elaborate.

Are you willing to attend an EMT course? *

Yes

Please list any previous affiliation with Fire, EMS, or Emergency Services (location, dates of service, type of membership).

Do you have any physical, medical, or other restrictions that may affect your duties as a squad member? *

Yes

If yes, please explain.

Please provide two personal references that you have known for at least one year (not relatives or members of HBES).

Reference 1 (include full name, address, and primary phone number) *

Reference 2 (include full name, address, and primary phone number) *

How would HBES benefit from having you as a member? *

I have, to the best of my knowledge and ability, answered all questions for reference purposes and hereby give my consent to any investigation. I also agree to abide by the rules and regulations of HBES and also agree to return any squad equipment issued to me upon request of the Chief, President, or designee. (Your typed name will act as a digital signature)

Full Legal Name *

If the applicant is a cadet, parent or legal guardian full legal name (your typed name will act as a digital signature).

Please download and complete the file below. Background checks should be completed prior to your interview.

https://drive.google.com/file/d/0B1Ufu2v8BLMRbl9fc1lsdzFidHM/view?usp=sharing

A copy of your responses will be emailed to the address you provided.

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