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Emergency: Dial 911

Non-Emergency Dipsatch: 573-897-3107

Office: 573-897-0044

Schedule Transfer: 1-888-612-6013

Osage Ambulance District logo featuring a tipi, two feathers, river, trees, medical star of life, and "EST. 1973" text on a dark green background.
Osage EMS logo with a red heartbeat line and text stating service to Osage, Gasconade, and Maries Counties.
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Enrollment Application

"*" indicates required fields

Step 1 of 9

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COURSE INFORMATION

Course Level:*
Course Title:*
Course Title:*
Course Title:*
Course Title:*

PERSONAL INFORMATION

Address:*
Are you a United States Citizen?*
Are you legally able to work in the United States?*

IN CASE OF EMERGENCY

Emergency Contact 1
Name:
Address:
Emergency Contact 2
Name:
Address:

EDUCATION INFORMATION

DRIVING EXPERIENCE

Do you have a valid driver's license?*
State DMV Licensed?
Can you travel if a job requires it?
Have you ever driven an emergency vehicle?
Leave blank if none.
Leave blank if none.
Has your license ever been suspended or revoked?
Have you attended a VFIS Emergency Vehicle Operator’s Course with Osage Ambulance District?

EMPLOYMENT

Current / Most Recent Employer
Business Address:
Previous Employer
Business Address:

REFERENCES

Reference 1
Name
Reference 2
Name
Reference 3
Name

SHORT PARAGRAPH

SIGNATURE AND CONFIRMATION

I hereby declare that the information provided in this application is true and correct. I also understand that any willful dishonesty may be grounds for immediate denial of this or any future applications.*
Osage Ambulance District logo featuring a tipi, two feathers, river, trees, medical star of life, and "EST. 1973" text on a dark green background.
Osage Ambulance District

119 S. Highway 89
Linn, Missouri 65051

Emergency: Dial 911
Non-Emergency Dispatch: 573-897-3107
Administrative Office: 573-897-0044
Schedule A Transfer: 1-888-612-6013
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