Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Note: We are Darien EMS in Western New York. We have no affiliation with Darien EMS in CT.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

What position(s) are you interested in?

Driver

Emergency Medical Technician (EMT)

Advanced Emergency Medical Technician (A-EMT)

Paramedic (EMT-P)

Other

Do you have a valid New York State Drivers License? *

Yes

No

Years of E.M.S. Experience

0

1-2

3-5

5-10

10+