Last Name:

First Name:

MI:

Social Security #:

- -

Address:

Apt/Suite:

City:

State:

Zip Code:

Phone #: - -     Pager/Cell: - -

Email:

Are you 18 years of age or older?

Yes

No

If no,state your age.

Do you have a New York State Drivers License ID?

Yes

No

If yes what is your Driver License ID:    - -

Please check appropriate time periods

Weekdays:  Days:   Evenings   Nights

Weekends:  Days:   Evenings   Nights

Other Information

Name of Agency:

Contact Person

Address

City

State

Zip Code

Phone

- -

Responsibilities

CPR

Exp. Date:

/ /

First Aid

Exp. Date:

/ /

EMT-D

Exp. Date:

/ /

Certification #:

EMT-I

Exp. Date:

/ /

Certification #:

Paramedic

Exp. Date:

/ /

Certification #:

Other Relevant Training

Name

Tel#

- -

Address

City

State

State... AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE ND NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY

Zip Code

Name

Tel#

- -

Address

City

State

State... AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE ND NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY

Zip Code

Name

Tel#

- -

Address

City

State

State... AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE ND NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY

Zip Code

Please list the names of any acquaintances that are members of this organization

Phone #

- -

Name

Relationship

WAIVER
** this part will be completed at time of interview **

It is required that we advise you that a routine inquiry will be made into this application that will provide applicable information concerning your personal character. All information will be kept in strict confidence.

I,, hereby give permission to the village of Mamaroneck EMS to verify information with the applicable Police Department concerning my character and advise you thereof for the purpose of becoming a member of the Mamaroneck Emergency Medical Services.

I understand that any false statements made hereon will automatically disqualify me from membership with the Mamaroneck Emergency Medical Services.

Signature: ____________________          Date: ____________________

IF YOU ARE A MINOR

Person under 18 years of age must have a parent or legal guardian sign this application to be considered for membership.

I,, give permission for to become a member of the Village of Mamaroneck Emergency Medical Services.

Signature of Parent or Legal Guardian: ____________________       Date: _______________

Have you ever been convicted of a felony?

Yes

No

Have you ever been a member of the United States Armed Forces?

Yes

No

If YES, did you receive a dishonorable discharge?

Yes

No

If the above answer to any of these questions is "YES", please give complete details in the space provided. For military service, please include service, branch, and service dates. This information is used with other factors to determine membership in our organization.