web application

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Current Certifications *

EMT/A-EMT/Paramedic Healthcare Provider CPR Driver's License None Apply

Do you have any relatives or friends working/volunteering here? If so, list their names *

Have you ever volunteered for this organization?, If so, date(s) and reason for leaving *

Have you ever been convicted, pled guilty, or no contest to a felony or misdemeanor, including a DUI/DWI or similar offense, had any moving violations, or had your license revoked or suspended? Choose One *

Yes No

If yes, explain: *

Most recent Employment/Volunteer History *

Choose One *

OK to Contact NOT OK to contact

I certify that the information I have given on this application is true, complete and correct, and I understand that any false information or the omission of important information may be considered as sufficient reason for the rejection of my application. I recognize that completion of this application does not mean that I am accepted as a member, and does not obligate the organization in any way to accept me. If accepted, membership will be “at will” and either the company or I is free to terminate the membership agreement at any time without cause and without prior notice. This application is not an agreement or a guarantee of membership. I hereby authorize PMES to investigate my volunteer/employment history with former employers and to make any further investigation deemed necessary in connection with my application for membership. I agree I will provide a criminal history check and child abuse clearance check. I release PMES and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished. *

Yes, I agree

certification *

Max file size: 20MB

PA Criminal Background Check *

Max file size: 20MB

PA Child Abuse Clearance *

Max file size: 20MB

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Volunteer Application