Application for Membership

St John Rescue, INC - PO Box 1225 St John, VI 00831

(340) 693 - 7377 - stjohnrescue@gmail.com - www.stjohnrescue.org

First, Middle Initial, Last Name

Date Of Birth

Month

Day

Year

Phone Number

Address

Employer

Position

Driver's License Number

State Issued

Have you ever had your license revoked or suspended?

Yes

If yes, when and what charge(s):

Moving violations within the past 5 years:

Have you ever been convicted of a crime?

Yes

If yes, when and what charge(s):

Are you interested in becoming a:

Responding Member

Supporting Member

List any current EMS certifications:

Do you hold a valid CPR or First Aid Card?

Yes

Type

Expiration Date

Any other organizations you belong to?

Please list other relevant qualifications, skills, or areas of special interest:

Do you have any allergies, medical, or physical restrctions?

Emergency Contact

Contact Phone

Reference #1

Contact Phone

Reference #2

Contact Phone

Upload Resume and/or Certifications

Signature

Date

St. John Rescue