First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Main Phone Number:

Email:

Company or School Name. Please state the number of years of employment or last grade completed. (required)

Company or School Address:

Company or School Phone Number:

Supervisor/Teacher:

ADDITIONAL QUESTIONS

Do you have a medical condition which in any way impairs or limits your ability to provide emergency medical care? “Medical Condition” means any physiological, mental, or psychological condition, impairment, or disorder including drug addiction of alcoholism.
YesNo

Have you within the past 5 years engaged in the illegal or improper use of drugs or other chemical substances?
YesNo

Have you ever been convicted of, found guilty, or entered a plea of no contest to a felony or misdemeanor crime? (other than minor traffic violation with fines under $10, 000)
YesNo

Has any state or other jurisdiction of the United States or any other nation ever limited, restricted, warned, censured, placed on probation, suspended, revoked or otherwise disciplined a license issued to you?
YesNo

Have you ever been sued in connection with your emergency medical functions in this or any other state?
YesNo

I hereby certify that the information provided on this registration form is true and correct to the best of my knowledge. I understand that providing false or misleading information may result in citation and warning, denial, probation, suspension or revocation of my membership in the Hull Ambulance and or state certification. I have read, understood, and am able to meet the qualifications laid out in the Bylaws to Articles of Incorporation for the Hull Emergency Medical Service.

Your (digital) Signature:
Date: