Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of birth: *

MM

DD

YYYY

Expiration date:

Level of EMS Training

MM

DD

YYYY

Are you CPR Certified? *

Yes

No

Expiration date:

CPR Certification

MM

DD

YYYY

Have you previously applied for membership? *

Yes

No

Are you a current or former member of another Ambulance or Fire Company? *

Yes

No

Have you ever been convicted of a Felony crime? (Do not include Misdemeanors) *

Yes

No

Please accept the following terms: *

Upon continuation of the application process you will be needed to provide:

A letter of recommendation from either a previous/current Employer or a Friend/Relative

A copy of your current Certifications (EMS and CPR cards)

A copy of your Driver's License

A $10.00 application fee payable to Boston Emergency Squad

Do you accept the above terms? *

Yes

No