UVAC Online Membership Application
Personal Information
Last Name
First Name
Middle Name
Date of Birth
Email
Contact Information
Local Address
City, State, Zip
Local Phone
Home Address
City, State, Zip
Home Phone
University Affiliation
Year in school:
First Year
Sophomore
Junior
Senior
Graduate Student
Not a Student
Expected Graduation Month
May
Aug
Dec
Grad Year
Please describe your affiliation with the UMaine community in Orono, including jobs and involvement with other organizations.
Background
Are you able to lift 50lbs from the ground to standing height?
Yes
No
If no, please explain:
Have you ever been convicted of any crime other than a minor traffic violation?
Yes
No
If yes, please explain:
EMS and other Medical Experience
If licensed, please select your current State of Maine license level:
EMT-B
EMT-I
EMT-P
Expires:
Please list any medical experience, including courses and employment. Give applicable contact information, dates of employment, description of position, and reasons for leaving:
Personal Essay (150-500 words)
What benefits will be derived from your working in the Emergency Medical field? How will UVAC benefit from your participation? What growth do you expect to see in yourself through this experience?
References
Please give the following information on two references. These may be friends, colleagues, teachers, employers, etc.
Reference #1
Name
Address
Phone Number
Relation
# of years known
Reference #2
Name
Address
Phone Number
Relation
# of years known
Person to notify in case of an emergency
Name
Address
Phone Number
Relation
Certification by Applicant
Please read carefully before submitting.
In complying with the letter and spirit of applicable laws and pursuing its own goals of diversity, the University of Maine shall not discriminate on the grounds of race, color, religion, sex, sexual orientation, including transgender status or gender expression, national origin, citizenship status, age, disability, or veteran's status in employment, education, and all other areas of the University System. The University provides reasonable accommodations to qualified individuals with disabilities upon request.
By submitting this form after entering my name and today's date below, I certify that all answers and statements contained herein are true to the best of my knowledge and belief. I understand that any misstatements or concealment of material facts will subject me to DISQUALIFICATION before appointment or DISMISSAL after appointment. Furthermore, I understand that my application will not be considered complete until I have signed and/or submitted all required documentation and a background check has been completed.
Full Name
Date
Application last updated March 5, 2011.