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JEMA Application
Thank you for your interest in the Jacksonville Emergency Medical Auxiliary
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Email
*
Your email
Name
*
First and last name
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Address
*
Your answer
Phone number
*
Your answer
Which position are you interested in?
*
Choose
Paramedic
EMT
Nurse
Provider (Doctor, Nurse Practitioner, PA)
What is your license number?
*
Your answer
Are you National Registered? If yes, what is your number.
*
Your answer
What is your ACLS/BLS expiration date?
*
MM
/
DD
/
YYYY
Please list your Driver License and other EMS Certification and License.
*
Your answer
Do you have any tattoos below the wrist and/or above the neck?
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Choose
No
Yes
Why do you want to be a member of JEMA?
*
Your answer
Have you ever worked as a first responder before? (If yes, please list organizations, role, and date)
*
Your answer
Please list any community activities / organizations to which you belong.
Your answer
Please List 3 references that are not relatives with relationship and contact information.
*
Your answer
Emergency Contact
*
Your answer
Have you ever pleaded "nolo contendere" to, been convicted of, or found guilty of a first degree misdemeanor or felony?
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Choose
No
Yes
Shirt Size
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XS
S
M
L
XL
XXL
Other:
How did you here about JEMA?
*
From a JEMA Member
From a JFRD Employ
From a Flyer
From
myjfrd.com
From CoJ.net
JEMA Presentation/Recruiter
JEMAuxiliary.org
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