Bunn Rescue & EMS INC.

Date:______________

Name:___________________________________________________________________________

Street Address:____________________________________________________________________

City:_________________________________ State:____________ Zip Code:__________________

Home Telephone # :____________________  Work Telephone #:____________________________

Emergency Contact: _____________________Relationship:__________ Telephone: #___________

Birth Date:________Age: ______Sex: ______Social Security Number:_______________________

Drivers License Number: _________________TB Test: Yes ____   No ____ Date: _____________

Hepatitis B Vaccine: Yes  ____   No ____         Date: ___________

Certification Level - Circle:  MR    EMT B   EMT D   EMT I   EMT P

Additional Certifications:____________________________________________________________

Are all Certifications listed under your current Name: Yes:  ____   No ____

If No list others names your certifications are under: _____________________________________

Currently with a Department or Provider: Yes ____   No ____   How Long: __________________

If Yes Department Name: ____________________ Department Address: ____________________

Have you ever been charged with a Felony: Yes ____   No ____

Please provide and attach a Copy of Social Security Card - Drivers License and All Certifications

I understand and agree that by filing this application I am stating that I am capable of meeting the requirements of the position.  The information that I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any facts in my application or any other materials can be justification for refusal of membership or termination from  Bunn Rescue & EMS  INC.

Signature of Applicant:_____________________________________________ Date: __________

Print Complete Name:_____________________________________________________________

Office Use Only

Applicant Accepted: Yes ___ No ___ Approved by: ______________________Date:__________

If No Why:_______________________________________________________________________

Applicant Notified: Yes ___   No ___   By Whom: _________________________Date:________

Authorization for Release of Personal Information to Law Enforcement Agencies for Certification/Employment Purposes

To Whom It May Concern:

I am an applicant for a position with the Franklin County EMS System as a paid employee or volunteer employee.  In order to determine my suitability for employment, I understand that the Franklin County Sheriff’s Office of Louisburg, North Carolina must make a thorough investigation of my personal records and personal background, it is in the public’s interest that all relevant information concerning my personal and employment history be disclosed to the above agency.

Therefore, I _________________________, DOB__________, Operators License #_____________, do hereby request and authorize any bank, credit union, lending or financial institution, credit bureau, consumer report agency, retail business establishment, former and present employer, educational institution, doctor or other health care professional including mental health, alcohol treatment center, hospital or other repository of medical records, insurance company, governmental agency, criminal and civil courts, certification/licensing commission, military organization, and any other individual agency to produce and provide copies of any and all information to the authorized agent of the Franklin County Sheriff’s Office of Louisburg, North Carolina regarding me whether of a privileged or confidential nature.

Moreover, I hereby release the Franklin County Sheriff’s Office of Louisburg, North Carolina from any civil or criminal liability whatsoever for seeking such requested information and for evaluating such information as it relates to my employment with the Franklin County EMS System. And, I hereby release the issuing agency and its agents, both collectively, from any and all liability for damages of whatever kind, which may at any time result because of compliance with this authorization and request.

I further waive all right to inspect or review any information compiled in reference to my application for employment. I do further hereby authorize the Franklin County Sheriff’s Office, its agents and employees, to release copies of any and all information to any agency or entity regulating the certification, authority or conduct of Franklin County EMS System personnel as authorized  in GS 114-19.12. This is to include, but not limited to: Franklin County Office of Emergency Services, NC Office of Emergency Medical Services and the applicants employing agency.

I hereby acknowledge that this authorization is valid for one (1) year or until the employment process has been completed, whichever is later.

A copy of this document is considered valid, just as the original.

I have read and fully understand the above statements.

Applicant Signature____________________________________

PrintedName________________________________________

Address: _____________________________________________

Phone Number: _____________________________________

SS#_________/_________/__________

STATE OF NORTH CAROLINA

COUNTY OF _____________

Subscribed and sworn to before me,

this is the ____day of ________, _______.

___________________________________

Notary Public & Seal

My Commission Expires: ______________

Authorities:  NC General Statute 114-19.12.