LASD EMT Stat Form:  Return to RFB Sgt Schuessler

 

Last Name:

First Name:

MI:

EMS Level (MD, PA, RN, EMT):

Cert #:                                                                         Date of Most Recent Class:

Card Exp Date:                                                           Four Year Exp Date

Employee #:

Soc Sec #:

DOB:

Age:

Blood Type:

Height:

Weight:

Hair:

Eyes:

Home Address:

Home City:

Home State:

Home Zip:

Division:

Station:

Assignment:

Picture:

 

Comments:

Level:

Rank:

Inducted:

Years of Service:

Occupation:

Job Title:

Employer:

Work Address:

Work City: