Georgetown Medical Assist Team Application For Membership _____________________________________ ____________________ Full Name (Last, First, Middle) Social Security # _______________________________________________________________________ Mailing Address City State Zip _______________________________________________________________________ Physical Address (if different than above) _________________ _________________ _________________ ______________ Email Address Home Phone Work Phone Mobile Phone _______________________________________________________________________ Employer/School Address City St. Zip _______________________ _____ _________________ ___/___/_____ Driver’s License Number State Class Date Of Birth Please list below any moving violations you have received in the past 3 (three) years Charge Date Location Disposition _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Use other side of page if needed Have you ever pleaded guilty or been convicted of any crime, either civilian or military? Yes No If yes, please list the charge(s), location(s), and disposition(s). Use any additional space on the reverse side of this page. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Circle your level of TX certification: NONE ECA EMT-B EMT-I EMT-P ___________________________ _____________________ ___________________ Date & location of course Certification expires TDH ID Number Why do you want to join Georgetown Medical Assist Team?________________ _______________________________________________________________________ _______________________________________________________________________ Do you have any prior EMS experience? Yes No If yes, please explain_________________________________________________ _______________________________________________________________________ _______________________________________________________________________ List below any other schools or training you feel will help you in the EMS field._____________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ I _______________________________ hereby certify that the above information is true and correct to the best of my knowledge. I understand that any misinformation or omission of information will be reason for immediate dismissal from Georgetown Medical Assist Team (GMAT). I hereby give permission to GMAT to investigate any and all of the information listed in this application to the degree deemed necessary by its officers. I also give permission to request and acquire a copy of my driving record, any police record(s) or military records necessary in the investigations. ________________________________________ Printed or typed name ________________________________________ Signature ________________________________________ Date _______________________________________________________________________ _______________________________________________________________________ For GMAT use only Investigation completed __________ DL check completed ________ Approved ______ Date ____________ Probation completed _______ Denied ______ Date ____________ Date ________