Note: This application is for certified Virginia EMS providers seeking ALS release to general supervision.
Full Name
Date
Full Address
Certifications, Documents, and Identification – Submit current copies of all the following: (enter date of expiration if no expiration date, enter date of initial certification)
Upload File(s)
Uniforms - For Department of EMS members only
To applicant’s immediate supervisor, The applicant must have this application signed by their immediate supervisor that may include the following: VB Rescue Squad Commander, Assistant Squad Commander, VBEMS Captain, VBFD Captain, or VBFD EMS liaison.
By signing below verifies that the applicant is a member in good standing and approves the applicant for consideration for an ALS Field Clinicals with the City of Virginia Beach Department of EMS.
Supervisor Name
With submission of this application, I understand that, at time of application and continuing until all contract obligations are met, I must:
Applicant Name & Signature: