Please provide all information requested or you can dowload the form, fill out and send back to us.
Name (First, M.I.,Last)
City, State, Zip
Are you 18 yrs or older?
Please give only references which you have known for at least 5 years.
(no Clergy, family members or Corps members)
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?
B. present employer?
If answer is “Yes” to either (a) or (b) , please explain
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?
Except for minor traffic violations, were you ever been convicted
of any violation of the law?
Current or former member of an Ambulance Corps or
Do you have anyphysical
disabilities or limitations?
Which shift would you
prefer to ride?
6AM to Noon
Noon to 6PM
6PM to Midnight
What day or days would be most convenient for you?
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.
or print out and mail to:
Yorktown Volunteer Ambulance Corps
PO Box 104
Yorktown Heights, NY 10598
Attn: Membership Committee Chairperson