Home » Joining MLEMS » Request Membership Information Sunday, July 6, 2008

Request More Information

In order to become a member of our organization, you must fill out an application and submit it. More information and an application may be requested using the form below. Alternatively, you may download the application in PDF form, print it and fill it out for submission.

Once your application has been submitted, it will be reviewed by members of the department. If you are age 18 or above, you will also be asked to submit to a background check. Questions may be directed to operations@mlems.org.

Personal Information

First Name
Last Name
Date of Birth ,

Contact Information

Street Address
City
State
Zip Code
Home Phone
Email Address

Prior Training

EMT Certified Yes, I am currently certified as an EMT in the State of New Jersey.
EMT Class Yes, I am currently enrolled in an EMT-Basic class in the State of New Jersey.