1. education
2. high school

TOMS RIVER EMERGENCY MEDICAL SERVICES
11 IRONS STREET
TOMS RIVER, NEW JERSEY 08753
Toms River Emergency Medical Services is an equal opportunity department. Toms River Emergency Medical Services considers
applicants for all positions without regard to race, creed, color, national origin, ancestry, age, religion, gender, disability which can be
reasonably accommodated without undue hardship, marital status, affectional or sexual orientation, veteran status, genetic
information, atypical hereditary cellular or blood trait or any other legally protected characteristic.
Date: ___________________
Social Security Number:
□□□ □□ □□□□
Driver License Number: ________________________ State: ______
_____________________________________________________
Last Name
First Name
Middle Name
_____________________________________________________
Street Address
City
State
Zip Code
How long have you lived at your current address: _______ Years _______ Months
Home Phone Number: (_____)________________
Email Address: ________________________________
Cell Phone Number:
Other Contact Information: (Please Specify)
(_____)________________
Work Phone Number: (_____)________________
Date of Birth:
_____________________________________________
□□ □□ □□□□
Place of Birth: (Complete Address)
┌
Height: ______Ft. ______In.
Weight: _________Lbs.
Hair Color: __________
Eye Color: _________
┐
_____________________
_____________________
_____________________
_____________________
└
┘
Will you be over the age of (18) eighteen on or before the application completion date:
Have you ever applied for or held membership with this agency in the past:
If yes, please document outcome:
□ Yes □ No
□ Yes □ No
__________________________________________________________________________________
__________________________________________________________________________________
Position applying for: ____________________________________________________________
How were you informed of this position: _____________________________________________
□ Yes □ No
Can you perform the duties of the job you are applying for:
Date:
Signature of Applicant:
Page 1
TOMS RIVER EMERGENCY MEDICAL SERVICES
11 IRONS STREET
TOMS RIVER, NEW JERSEY 08753
Current Certifications
List all certification, license, endorsement, certificate, and accreditation that have been issued to you. With this
application packet please attach as the last page a copy of:
Current Driver License, Current EMT certification, Current CPR certification.
Emergency Medical Technician
Basic
Expiration Date:
Emergency Medical Technician
Paramedic
Expiration Date:
Emergency Medical Technician
Other:
Expiration Date:
□ Yes □ No
State of Issue:
Certification Number:
□ Yes □ No
State of Issue:
Certification Number:
□ Yes □ No
State of Issue:
Certification Number:
□ Yes □ No
AHA, Red Cross, or ASHI CPR for the Healthcare Provider
Expiration Date:
┌
┐
Incident Command System
□ Yes □ No
□ Yes □ No
□ Yes □ No
100
300
700
□ Yes □ No
□ Yes □ No
□ Yes □ No
200
400
800
Other Incident Command System Certificates: _____________________
_____________________
_____________________
└
┘
□ Yes □ No
Coaching the Emergency Vehicle Operator (CEVO)
Level:
Expiration Date:
□ Yes □ No
Firefighter Level One
State:
Certification Number:
┌
┐
Hazardous Materials
Awareness
Technician
□ Yes □ No
□ Yes □ No
Operations
Specialists
□ Yes
Incident Commander
□ Yes □ No
□ Yes □ No
□ No
└
Date:
┘
Signature of Applicant:
Page 2
TREMS FORM 901
TOMS RIVER EMERGENCY MEDICAL SERVICES
11 IRONS STREET
TOMS RIVER, NEW JERSEY 08753
Other Certifications:
Certification
State
Number
THIS SECTION INTENTIONALLY LEFT BLANK
Date:
Signature of Applicant:
Page 3
TREMS FORM 901
Expiration
TOMS RIVER EMERGENCY MEDICAL SERVICES
11 IRONS STREET
TOMS RIVER, NEW JERSEY 08753
Work History
Please list all work history for the past five years. Start with one as your most recent employer. Include
volunteer employers and all lapses in employment during the past five years. If currently employed, check box
and place current date in end date. If more space is needed, attach a white sheet of paper to the back of this
application packet, label the top “Work History Continuation”. List the remainder of the required information.
Date the bottom left corner, sign the bottom right corner and number the page accordingly.
ONE
Employer:
Position:
Address:
_____________________________________
__________________________ ________________ _____________________________________
Description of Duties:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Start Date:
End Date:
Supervisor:
Phone Number:
____________ ____________
□ Current Employer
___________________________________ __________________
TWO
Employer:
Position:
Address:
_____________________________________
__________________________ ________________ _____________________________________
Description of Duties:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Start Date:
End Date:
Supervisor:
Phone Number:
____________ ____________
□ Current Employer
Date:
___________________________________ __________________
Signature of Applicant:
Page 4
TREMS FORM 901
TOMS RIVER EMERGENCY MEDICAL SERVICES
11 IRONS STREET
TOMS RIVER, NEW JERSEY 08753
THREE
Employer:
Position:
Address:
_____________________________________
__________________________ ________________ _____________________________________
Description of Duties:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Start Date:
End Date:
Phone Number:
Supervisor:
____________ ____________
□ Current Employer
___________________________________ __________________
FOUR
Employer:
Position:
Address:
_____________________________________
__________________________ ________________ _____________________________________
Description of Duties:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Start Date:
End Date:
Phone Number:
Supervisor:
____________ ____________
□ Current Employer
___________________________________ __________________
FIVE
Employer:
Position:
Address:
_____________________________________
__________________________ ________________ _____________________________________
Description of Duties:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Start Date:
End Date:
Phone Number:
Supervisor:
____________ ____________
□ Current Employer
Date:
___________________________________ __________________
Signature of Applicant:
Page 5
TREMS FORM 901
TOMS RIVER EMERGENCY MEDICAL SERVICES
11 IRONS STREET
TOMS RIVER, NEW JERSEY 08753
Education History
Please list all education from high school to present day. Start with one as your most recent educational
institution attended. Include any technical or specialized training.
ONE
Institution:
Address:
Course of Study:
Degree/Diploma:
___________________ ___________________
___________________ ___________________ _________________________ _____________
Start Date:
End Date:
___________________ ___________________
□ Currently Enrolled
□ Yes □ No
Did You Graduate:
TWO
Institution:
Address:
Course of Study:
Degree/Diploma:
___________________ ___________________
___________________ ___________________ _________________________ _____________
Start Date:
End Date:
___________________ ___________________
□ Currently Enrolled
□ Yes □ No
Did You Graduate:
THREE
Institution:
Address:
Course of Study:
Degree/Diploma:
___________________ ___________________
___________________ ___________________ _________________________ _____________
Start Date:
End Date:
___________________ ___________________
□ Currently Enrolled
□ Yes □ No
Did You Graduate:
Date:
Signature of Applicant:
Page 6
TREMS FORM 901
TOMS RIVER EMERGENCY MEDICAL SERVICES
11 IRONS STREET
TOMS RIVER, NEW JERSEY 08753
FOUR
Institution:
Address:
Course of Study:
Degree/Diploma:
___________________ ___________________
___________________ ___________________ _________________________ _____________
Start Date:
End Date:
___________________ ___________________
□ Currently Enrolled
□ Yes □ No
Did You Graduate:
FIVE
Institution:
Address:
Course of Study:
Degree/Diploma:
___________________ ___________________
___________________ ___________________ _________________________ _____________
Start Date:
End Date:
___________________ ___________________
□ Currently Enrolled
□ Yes □ No
Did You Graduate:
THIS SECTION INTENTIONALLY LEFT BLANK
Date:
Signature of Applicant:
Page 7
TREMS FORM 901
TOMS RIVER EMERGENCY MEDICAL SERVICES
11 IRONS STREET
TOMS RIVER, NEW JERSEY 08753
Residence History
Please list all places of residency during the past five years. Start with your last residence in one. If you have
resided at your current address for five years or more on or before the application completion date please check
“Not Applicable” below and do not fill this section in.
□ Not Applicable
ONE
Street Address:
City:
County:
State:
Zip Code:
_______________________ _______________ ______________ ____________ ____________
From: ___________________
To:_____________________
TWO
Street Address:
City:
County:
State:
Zip Code:
_______________________ _______________ ______________ ____________ ____________
From: ___________________
To:_____________________
THREE
Street Address:
City:
County:
State:
Zip Code:
_______________________ _______________ ______________ ____________ ____________
From: ___________________
To:_____________________
FOUR
Street Address:
City:
County:
State:
Zip Code:
_______________________ _______________ ______________ ____________ ____________
From: ___________________
To:_____________________
FIVE
Street Address:
City:
County:
State:
Zip Code:
_______________________ _______________ ______________ ____________ ____________
From: ___________________
To:_____________________
Date:
Signature of Applicant:
Page 8
TREMS FORM 901
TOMS RIVER EMERGENCY MEDICAL SERVICES
11 IRONS STREET
TOMS RIVER, NEW JERSEY 08753
References
Please list three references below. Family members are restricted from being utilized as a reference.
ONE
_________________________________________________________________________________________________
Name
Address
Phone Number
_________________________________________________________________________________________________
Occupation
Relationship
Years Known
TWO
_________________________________________________________________________________________________
Name
Address
Phone Number
_________________________________________________________________________________________________
Occupation
Relationship
Years Known
THREE
_________________________________________________________________________________________________
Name
Address
Phone Number
_________________________________________________________________________________________________
Occupation
Date:
Relationship
Signature of Applicant:
Page 9
TREMS FORM 901
Years Known
TOMS RIVER EMERGENCY MEDICAL SERVICES
11 IRONS STREET
TOMS RIVER, NEW JERSEY 08753
Background Information
NOTE: You need not list any conviction which has been pardoned, annulled, expunged, sealed or statutorily eradicated. A
conviction record will not necessarily bar an applicant from membership. Factors such as relation to the job, age and time
of offense, seriousness and nature of violations, and efforts at rehabilitation will be taken into account.
Have you ever been convicted of a criminal offense other than a minor traffic violation.
□ Yes □ No
Have you ever been placed into a diversionary, pre-trial intervention (PTI), or probation
program
□ Yes □ No
.
If yes to the above two questions, please give a brief overview. If no, please mark this section “N/A”:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Have you ever had a driver license suspended, revoked, or placed into a probationary state.
□ Yes □ No
(Excluding initial provisional driver license)
How many points, if any, has the Motor Vehicle Commission assigned to your current driving record:
□ Zero □ One □ Two □ Three □ Four □ Five □ Six or more
□ Yes □ No
□ Yes □ No
Have you ever been bonded.
Were you ever refused bond.
Military Background
Have you ever served in any branch of the United States military:
□ Yes □ No
If yes to the above question, Please fill in the following. If no, leave the below section blank:
Branch:
Occupation:
________________________________________ ________________________________________
Rank at Time of Discharge:
Period of Service:
________________________________________ ________________________________________
Specialized Training: (if any)
__________________________________________________________________________________
__________________________________________________________________________________
Date:
Signature of Applicant:
Page 10
TREMS FORM 901
TOMS RIVER EMERGENCY MEDICAL SERVICES
11 IRONS STREET
TOMS RIVER, NEW JERSEY 08753
Additional Information
Please utilize this section to document other information not already listed that may be pertinent to the
department during review of your application packet. If you feel that nothing more needs to be reported please
mark the section below with “N/A”.
Date:
Signature of Applicant:
Page 11
TREMS FORM 901
TOMS RIVER EMERGENCY MEDICAL SERVICES
11 IRONS STREET
TOMS RIVER, NEW JERSEY 08753
Applicant's Statement
I certify that answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for membership as may be
necessary in arriving at a membership decision.
I understand that I may be required to satisfactorily complete a pre-membership drug test, driver and criminal
background, medical and or/psychological examination as a condition of membership.
I understand that Toms River Emergency Medical Services may conduct an investigation in addition to review
of my application packet and supporting documentation. I understand that I have provided consent to duly
authorized agents of Toms River Emergency Medical Service to conduct this investigation and I have signed,
as required, the TREMS FORM 902 - Authorization for Release of Information.
This application for membership shall be considered active for a period of time not to exceed one
year. Any applicant wishing to be considered for membership beyond this time period should inquire
as to whether or not applications are being accepted at that time.
In the event of membership, I understand that false or misleading information given in my application
or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and
regulations of the Toms River Emergency Medical Services.
SIGNATURE (APPLICANT):
PRINT NAME (APPLICANT):
Date:
Signature of Applicant:
Page 12