CRIMINAL AND DRIVING HISTORY (CCH/DMV record check form must be attached to this application)
Have you ever been convicted of a crime other than traffic offenses? _____ Yes _____ No
If yes, explain:_____________________________________________________________________
________________________________________________________________________________
Have you ever been convicted of a traffic offense in the past 7 years? _____ Yes _____ No
If yes, explain:_____________________________________________________________________
________________________________________________________________________________
EMPLOYMENT:
Current or Last Place of Employment: ____________________________________________________
Dates of Employment: _____________ Shift(s) worked: _____ Position(s) Held __________________
Last Supervisor’s Name: ______________________________ Phone# _________________________
Previous Place of Employment: _________________________________________________________
Dates of Employment: _____________ Shift(s) worked: _____ Position(s) Held __________________
Last Supervisor’s Name: ______________________________ Phone# _________________________
Previous Place of Employment: _________________________________________________________
Dates of Employment: _____________ Shift(s) worked: _____ Position(s) Held __________________
Last Supervisor’s Name: ______________________________ Phone# _________________________
REFERENCES:
List three individuals who are not related to you nor are a member of this rescue squad.
(1) _______________________________________________ Ph#:__________________________
(2) _______________________________________________ Ph#:__________________________
(3) _______________________________________________ Ph#:__________________________
By signing this form, you acknowledge that:
1. if you do not possess current certifications, you must complete these courses within designated
period of being accepted
(may vary depending on agency you are applying to)
CPR – Within _____ Months First Aid – Within _____ Months
EVOC – Within _____ Months EMT-Basic – Within _____ Months
Firefighter I – Within ____ Months
2. you will be expected to adhere to all rules and regulations, as they may apply, that are
established by this agency, Henry County, and/or the Commonwealth of Virginia.
SIGNATURE__________________________________________________ DATE _____________
(Any applicant under the age of 18 must obtain a parent/guardian signature as well)
PARENTS SIGNATURE _________________________________________ DATE _____________
RECEIVED BY _________________________________________________ DATE _____________
EMS agency applicant SHALL meet, before affiliation, and maintain compliance with the following
general requirements: (Fire Department applicant MAY be required)
1. Be a minimum of 16 years of age. (An EMS agency may have associated personnel who are less than 16
years of age. This person is not allowed to participate in any EMS response, or any training program or other
activity that may involve exposure to a communicable disease, hazardous chemical or other risk of serious
injury.)
2. Be clean and neat in appearance;
3. Be proficient in reading, writing and speaking the English language in order to clearly communicate with a
patient, family or bystander to determine a chief complaint, nature of illness, mechanism of injury and/or assess
signs and symptoms.
4. Have no physical or mental impairment that would render him unable to perform all practical skills required for
that level of training. Physical and mental performance skills include the ability of the individual to function and
communicate independently to perform appropriate patient care, physical assessments and treatments without
the need for an assistant.
5. Applications by individuals convicted of certain crimes present an unreasonable risk to public health and
safety. Thus, applications for certification by individuals convicted of the following crimes will be denied in all
cases:
A. Felonies involving sexual misconduct where the victim's failure to affirmatively consent is an element of
the crime, such as forcible rape.
B. Felonies involving the sexual or physical abuse of children, the elderly or the infirm, such as sexual
misconduct with a child, making or distributing child pornography or using a child in a sexual display,
incest involving a child, or assault on an elderly or infirm person.
C. Any crime in which the victim is an out-of-hospital patient or a patient or resident of a healthcare facility
including abuse of, neglect of, theft from, or financial exploitation of a person entrusted to the care or
protection of the applicant.
D. Serious crimes of violence against persons such as assault or battery with a dangerous weapon,
aggravated assault and battery, murder or attempted murder, manslaughter except involuntary
manslaughter, kidnapping, robbery of any degree, or arson.
6. Applications by individuals in the following categories will be denied except in extraordinary circumstances,
and then will be granted only if the applicant or provider establishes by clear and convincing evidence that
certification will not jeopardize public health and safety.
A. Applications by individuals who have been convicted of any crime and who are currently incarcerated, on
work release, on probation, or on parole.
B. Applications by individuals convicted of crimes in the following categories unless at least five years have
passed since the conviction or five years have passed since release from custodial confinement
whichever occurs later:
a. Crimes involving controlled substances or synthetics, including unlawful possession or distribution
or intent to distribute unlawfully Schedule I through V drugs as defined by the Virginia Drug
Control Act (§ 54.1-3400 seq. of the Code of Virginia).
b. Serious crimes against property, such as grand larceny, burglary, embezzlement, or insurance
fraud.
c. Any other crime involving sexual misconduct.
C. Has been subject to a permanent revocation of license or certification by another state EMS office or
other recognized state or national healthcare provider licensing or certifying body.
My signature below indicates that I have read and fully understand all the requirements of Fire
and/or EMS personnel in the Commonwealth of Virginia.
SIGNATURE__________________________________________________ DATE _____________
(Any applicant under the age of 18 must obtain a parent/guardian signature as well)
PARENTS SIGNATURE _________________________________________ DATE ______________
