Application

Please provide all information requested or you can dowload the form, fill out and send back to us.

Name (First, M.I.,Last)

Street Address

City, State, Zip

Home Phone Alternate Phone

Are you 18 yrs or older? Yes     No

References: Please give only references which you have known for at least 5 years.
(no Clergy, family members or Corps members)

1st Reference

2nd Reference

Name:

Address:

Phone:

Name of Friend or Relative in the Corps (if any)

Have you any objections to this organization making inquiries regarding your character and qualification from:

A. former employer? Yes     No

B. present employer? Yes     No

If answer is “Yes” to either (a) or (b) , please explain

Employment
Present

Former

Firm Name    Firm Name

Business Type Business Type

Education School Name
Year

Deg.

List your level of experiences including certificates and licensing pertaining to the medical profession
(CFR, EMT-D, EMT-I OR EMT-P, ETC.)

Certified in CPR?
No   Yes
Experation date:

Except for minor traffic violations, were you ever been convicted of any violation of the law?    No   Yes

Current or former member of an Ambulance Corps or Rescue Squad?                               No Yes

Agency Name:

Do you have any physical disabilities or limitations?
No   Yes

Which shift would you prefer to ride? Select one

What day or days would be most convenient for you? Mon Tue Wed Thurs
Fri   Sat Sun

Declaration: I declare, subject to the penalties of perjury, that the above statements made in this application have been examined by me and to the best of my knowledge are true and accurate.

Name

Date

or print out and mail to:
YVAC Headquarters
Yorktown Volunteer Ambulance Corps
PO Box 104
Yorktown Heights, NY 10598
Attn: Membership Committee Chairperson