LCEMS Application *protected content**protected content* Personal Information Name Address CityState/ProvinceZip/Postal Code Email Birthdate MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year 1901234567890123456789 Place of residenceRoom # Campus box: Phone number(extension) Cell Phone number Class Year Do you have a vehicle on campus? Yes No Interests and History Why are you interested in LCEMS? Are you currently involved with or thinking about joining any other organizations on campus? Are you currently employed? If yes, where do you work and how many hours per week? Can you meet more than the mandatory time commitment for LCEMS? If so, how much do you estimate? Please list any previous experience with an emergency medical service: Certifications Please date any certifications you possess, even if expired. CPR: Month Day Year EMT-B: Month Day Year Other: Month Day Year Cert Have you ever been charged or convicted of any misdemeanor or higher offense in any state? Where did you hear about LCEMS? Do you have any questions or comments you would like to add? References 1 Name Phone # Relation to you 2 Name Phone # Relation to you Interview Availability Please list a few times you are regularly available for a thirty minute interview during the week. I hereby certify that all the information on this application is true to the best of my knowledge. By entering my name below, I am signing this form as an electronic signature, and I am agreeing to allow University of Lynchburg EMS to complete a full background search and get a copy of my complete driving record. Name Date of completion Month Day Year
