Online Application Fields marked with a * are required Your Name * Street Address * City / State / Zip Code * Home Phone Number Cell Phone Number Email Address * You Are Applying For * EmploymentVolunteer MembershipJunior Membership Position You Are Applying For Driver's License State & Number Are You Eligble For Work In The United States? YesNo Certification #1: Issuing Authority Type Number Date Issued Expires Certification # 2 Issuing Authority Type Number Date Issued Expires Certification # 3 Issuing Authority Type Number Date Issued Expires Please Include Additional Certifications Below: Education: High School Name / City / State Did You Graduate? YesNo Trade or Technical School Name/City/State Did You Graduate? YesNo Certification College Name/City/State Degree/Major Did You Graduate? YesNo College #2 Degree/Major Did You Graduate? YesNo Employment: Current Employment May We Contact Your Employer? YesNo Employer Street Address City/State/Zip Employer Phone Number Who Should We Ask For? Dates of Employment Your Position & Duties Relevant Employment and Experience (EMS, Fire, Military Training and Experience) Please Note: Unless specified in a job description or advertisement, no experience is required to join. We can make use of many different skills and welcome the unique contributions of each member. IF you desire to work as an ambulance crew member, we will train you. You do not have to participate in emergency medical care. Employer/Agency Street Address City/State/Zip Who Should We Ask For? Dates of Employment Your Position & Duties Employer/Agency Street Address City/State/Zip Who Should We Ask For Dates of Employment Your Position & Duties Include Any Additional Experience Here Special Training and Skills that could be useful to Thousand Islands Rescue (Include Military Training). You may be asked to instruct. Shirt Size Waist Size Inseam Height Jacket Shoe Size THE PROCESS TO BECOME A MEMBER WILL INCLUDE: YOUR APPLICATION ADMINISTRATIVE REVIEW AND APPROVAL AS NEEDED PHYSICAL EXAM AND IMMUNIZATIONS AS REQUIRED COMPLETION OF ORIENTATION PROBATION Non-Discrimination Statement: TIERS Inc does not discriminate against any person on the basis of race, religion, color, gender, sexual orientation, age, national origin, disability, veteran status, family status or any other status or condition protected by law in the provision of services and in employment. Within the Freedom of Information Law, all information contained or obtained herein will remain confidential and will be used only for membership processing. MAKE SURE ALL INFORMATION IS CORRECT. BY SUMITTING ,YOU CERTIFY THAT YOU HAVE READ THE NON-DISCRIMINATION STATEMENT AND FREEDOM OF INFORMATION STATEMENT ABOVE. Anti-Spam: What Does 2+2=? *
