Thousand Islands Emergency Rescue Service, Inc.
100 Union Street
Clayton, NY 13624
315-686-2058

Online Application

Please enter your information into the boxes provided. Your application will be sent to TIERS management when you click on "Submit Application Form".

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You Are Applying For:        Employment              Membership              Junior Membership

Personal Information

Name (Last, First, Middle):

Today's Date:

Home Address:

City:

State:

Zip:

Home Phone:
Cell Phone:

Business or Work Phone:

Email Address:

Driver's License State and Number (a copy will be required):

Are you eligible to work in the United States?

Position You Are Applying For:
Certifications:
Issuing Authority/Type	Number	Date Issued	Expires:






Education Record
High School (Name, City, State):
Did You Graduate?
Trade or Technical School (Name, City, State):
Did You Graduate?	Degree or Certificate, Subject:
College 1 (Name, City, State):
Did You Graduate?	Degree, Major:
College 2 (Name, City, State):
Did You Graduate?	Degree, Major:


Current Employment
Employer	Dates Employed:	Can We Contact This Employer?
Address:
City:	State:	Zip:
Phone:	Who Should We Ask For?
Your Title/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/Department	Dates Employed:	Can We Contact This Employer?
Address:
City:	State:	Zip:
Phone:	Who Should We Ask For?
Your Title/Duties:
Employer/Agency/Department	Dates Employed:	Can We Contact This Employer?
Address:
City:	State:	Zip:
Phone:	Who Should We Ask For?
Your Title/Duties:
Employer/Agency/Department	Dates Employed:	Can We Contact This Employer?
Address:
City:	State:	Zip:
Phone:	Who Should We Ask For?
Your Title/Duties:

Special Training and Skills that could be useful to Thousand Islands Rescue (Include Military Training). You may be asked to instruct.

Uniform Size Information

Shirt

Waist

Inseam

Jacket

Shoes

Height

The process to become a member will include:

Your Application 4. Completion of Orientation
Administrative Review and Approval as Needed 5. Probation
Physical Exam and Immunizations as Required

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.
Please go back and confirm that you have entered complete and accurate information. Read the above Non-Discrimination Statement and Freedom Of Information Law statement. You will certify that you have done so by typing your name and the date in the boxes below. Click "Submit Application Form" to send the form.
Signature:
Date:

Personal Information
Name (Last, First, Middle):		Today's Date:
Home Address:
City:	State:	Zip:
Home Phone: Cell Phone:	Business or Work Phone:
Email Address:
Driver's License State and Number (a copy will be required):
Are you eligible to work in the United States?