Live-In Program

Benefits

• Free Private Dorm-Style Room
• Tuition Reimbursement
• Meal Allowance
• Free Internet
• Free Uniforms
• Free Training

Requirements

• Must Be At Least 18
• Maryland or NREMT
• Ambulance Driver
• Successful Physical and Background Check
• Student or Employed

How to Apply

• Complete the Online Application below
• Station Interview
• Committee Selection Process

Live-In Member Application

Personal Data

Last name *

First name *

Middle name

Nickname/Preferred name

Street address *

City *

State *

Zip code *

Email address *

Phone number *

Occupation

Driver’s License Number

State

Class

Has your Driver’s License ever been revoked ?

Yes

No

If your answer was “Yes” to the previous question. Please explain below.

Fire / Rescue, EMS Experience

Have you ever applied to or been a member of this department before?

Yes

No

If your answer was “Yes” to the previous question. Please explain below.

Have you ever served in another fire department, rescue squad or other emergency service organization?

Yes

No

Name of organization

Phone

State highest rank held or certifications

Street address

City

State

Zip code

Reason(s) for leaving

Training

Emergency Service Training/Education/Certification, course title, where taken and number of class hours: (Examples-Essentials of Firefighting, 125 hours, EMT-B)

Employment

Current Employer

Street address

City

State

Zip code

Phone

Dates employed from:

Dates employed to:

Education

Name and location of last high school attended

Highest grade completed

Did you graduate?

Yes

No

Date of graduation

Date of GED

Name and location of college or university attended

Number of credits or degree(s) awarded

Other relevant training that should be included in your emergency service file

Special skills, interests or hobbies

Foreign languages spoken and/or read

General

Have you ever been convicted/sentenced/placed on probation for a criminal offense or traffic offense in an adult court? (minor traffic offenses may be omitted).

Yes

No

If yes, give details, including date, charge, location and disposition of the case

References

Reference name

Reference Phone

Reference name

Reference Phone

How did you hear of this volunteer opportunity?

Poster

Gazzette Ad

TV Ad

School Event

County Fair

Internet *

Personal Contact *

OtherOther

If you made a selection above that has an * next to it, please elaborate on your choice.

PARENTAL AUTHORIZATION REQUIRED FOR ALL APPLICANTS UNDER THE AGE OF 18

I certify that the information provided in this form is true and complete to the best of my knowledge. I understand that, should any statement I have made prove to be false, misleading or erroneous, it may result in a delay or possible rejection of my application for membership.

Please complete the form below prior to submitting your application

If you are human, leave this field blank.

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