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Name
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Address
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Address
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State
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Years at Current Residence
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Do you have a Police Record?
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Police Record (explain)
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(In Submitting this Application you are Agreeing to a Criminal Background Check)
Do you Agree to be Substance Free while on Duty?
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List any Medical Conditions that would require Special Accommodations from F.B.A.
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Current Vaccinations
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Hepatitis
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Influenza
Tetanus
Shingles
Pnumonia
COVID-19
If you have not had the Hepatitis "B" vaccine F.B.A. will provide it, Otherwise you will be required to sign a Refusal Form.
Certification Level
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No Current Certification
Emergency Medical Responder (EMR)
Emergency Medical Technician (EMT)
Advanced Emergency Medical Technician (AEMT)
Paramedic(NRP)
VT First Responder
Additional Certifications
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NONE
BLS Instructor
ACLS
PALS
EVOC
PEPP
PHTLS
ITLS
CPR Instructor
Employment History
Employer Name
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Date Hired
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Date Left
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Supervisor Name
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Starting Pay
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Hourly
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Ending Pay
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Hourly
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May we Contact this Employer
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Employer Name
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Date Hired
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Starting Pay
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Hourly
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Ending Pay
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Salary
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Employer Name
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Date Hired
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Date Left
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Supervisor Name
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Starting Pay
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Hourly
Salary
Ending Pay
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Hourly
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About
House Calls
CPR & AED
Contact
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