Dentsville EMS & Auxiliary




2019 EMS Calls
Jan 68
Feb 70
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total 138

2019 Fire Calls
Jan 34
Feb 14
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total 48

Past Responses
Year EMS Fire
2018 919 345
2017 883 -
2016 787 -
2015 808 -
2014 738 -
2013 549 -
2012 655 -
2011 590 -
2010 517 -

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October 4, 2008
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Visitors Today
Apr 19, 2019
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Application for Membership


Federal and State law requires that all applicants be considered without regard to race, color, creed, sex, age, religion or national origin, marital status, sexual orientation, political or religious opinion or affiliations, and physical or mental handicap (except in such cases where the disability or condition would preclude the individual from adequately performing the task involved).

We believe in and fully support equal employment opportunity and will fulfill our obligation to the fullest.

Required   Indicates Required Field
Type of membership:
PERSONAL DATA
Name (Last, Middle, First): Required
Social Security #: Required
Age: Required
Date of Birth: Required
Sex: Required
Name preferred to be called:
Marital Status: Required
Address: Required
How long have you lived at this address?: Required
Home Phone:
Cell Phone:
Email Address: Required
Driver License No.:
State:
License Class:
License Experation Date:
Any Physical Handicap:
If yes describe:
Any Serious Illness:
If you have been convicted of a crime please describe:
Have you ever served with this or any other EMS/Fire company before: Required
If yes, when?:
Name of EMS/Fire Company:
Position:
Training Level:
Employment
Current Employer: Required
Employer Address: Required
Years at employer?: Required
Job Title: Required
Supervisor Name: Required
Business Phone: Required
Education
High School: Required
High School Graduate?: Required
Year Graduated:
School City:
School State:
High School GPA:
College:
College Graduate?:
Year Graduated College:
College City:
College State:
College GPA:
Trade Schools:
REFERENCES
Reference #1 (Name, Address & Phone Number): Required
Reference #2 (Name, Address & Phone Number): Required
Reference #3 (Name, Address & Phone Number): Required
EMERGENCY
In case of emergency, please notify: Required
Emergency Contact Address: Required
Emergency Contact Home Phone:
Emergency Contact Work Phone:
Emergency Contact Cell Phone:
Electronic Signature:
In submitting this application, I authorize investigation of all statements contained herein inclusive of a Criminal Background Check (18 years of age and older). I hereby authorize the Dentsville Volunteer EMS and Auxiliary, Inc. to make any contacts considered necessary to any person or organization listed on this application to release said information. I understand any misrepresentation by me in this application is sufficient cause for cancellation of this application.
Required
Application Submitted: 04/19/2019 1627
Parent or legal guardian Electronic signature:
If applicant is under 18 years of age, a parent or legal guardian must sign application

*This application must be submitted prior to our regular Membership Committee Meeting,
held the last Thursday of each month at 7:00 p.m.
If you cannot attend this meeting you must notify the Membership Committee Chairman @ (301) 392-0050.





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Dentsville EMS & Auxiliary
12135 Charles Street
P.O. Box 109
La Plata, MD 20646
Emergency Dial 911
Office: 301-392-0050
Fax: 301-392-5754
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