Serving to Save Lives

Thousand Islands
Emergency Rescue Service, Inc.
 100 Union Street
Clayton, NY 13624
315-686-2058
director@ti-rescue.org

Application
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Applying for:
Employment              Membership              Junior Membership

Personal Information

Name (Last, First, Middle):

Date:

 

Social Security Number:

Date Of Birth:

Home Address:

City:

State:

Zip:

Home Phone:
Cell Phone:

Business Phone:

Driver's License number (a copy will be required):

Email Address:

Position You Are Applying For:

Current Certifications (a copy will be required)

 Issued Expiration

Education Record

High School (Name, City, State):

Graduation Date:

Business or Technical School (Name, City, State):

Dates Attended:

Degree Earned:

Undergraduate College (Name, City, State):

Dates Attended:

Degree, Major:

Graduate School (Name, City, State):

Dates Attended:

Degree, Subject:

Current Employment

Employer

Dates Employed:

  

Address:

City:

State:

Zip:

Phone:

Title/Duties:

 

Please list experience in the Fire and EMS field you have had.
Include copies of current certifications

Agency, Address:

Job Description:

Dates:

Special skills that could be useful to Thousand Islands Rescue:

Uniform Size Information

Shirt

Waist

Inseam

Jacket

Shoes

Height

 

 

 

 

 

 

Process to become a member will include the following:

  1. Application
  2. Board of Directors - Operations Committee Approval
  3. Physical and Immunizations as Needed
  4. Orientation
  5. Probation

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, type your name and the date below to agree that you have done so.  Click "Submit Application Form" to send the form.

Signature:

Date: