Yorktown Ambulance Corps
Route 202
Yorktown Heights, NY
914-245-9822
 

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  anyphysical 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      
   

Captcha Code:

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

 

   

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