Thank you for applying to the Marbletown
First Aid Unit. Your
interest and desire to join the Rescue Squad will help us provide
quality emergency medical services to the Marbletown and Rosendale
communities. Please review the qualifications for membership prior
to completing the application.
Should you have any questions pertaining to membership please
call (845) 687-9847.
Please answer each question fully and accurately.
After we have received your application and have had an
opportunity to review it we will contact you to schedule an
interview.
Last Name:__________________ First Name:
_________________ Middle Initial:___
Sex: Male Female
Present Street
Address:______________________________________
City: _____________
State:__
Permanent Street
Address:____________________________________
City: _____________
State:__
Home Phone:
(____)____-________
Work Phone: (____)____-________
Pager: (___)____-_______
Age:_____ Date Of
Birth:___/___/_____ E-mail
Address: ___________________@_____________
Social Security Number (if accepted as a
member used for insurance purposes): ______-____-_______
Do you have a valid driver's license ?
Yes No
If yes, Drivers License
Number: __________________
State:___ Expiration
Date: ___/___/______
Do you have any restrictions on your
driver's license ? Yes No
If yes please list restrictions:
Have you had any accidents or moving
violations in the past four (4) years ? Yes
No
If yes please list:
Have you ever been convicted of a crime ?
Yes No
If yes provide particulars:
How were you referred to MFAU ?
(friend, relative, brochure, membership
drive, training class, etc-if referred by a Squad member please
include their name)
When will you be able to start volunteering
with the Squad ?
Please list any areas of special interest or
training:
Why do you want to join the Squad?
If you are available for a limited period of
time, include the specific dates: ___________To:__________
(ie: School semester, summer only etc.)
What Status are you applying for ? (check
all that apply):
ð
Active (riding member)
ð
Driver only (must be 21 years
of age)
ð
Medical personnel
Certification held:
ð
NYS Certified First Responder.
ð
NYS EMT Basic.
ð
NYS AEMT Intermediate.
ð
NYS AEMT Paramedic.
ð
Other:
Certification #:________________________ Expiration date: _________________
Auxiliary
Current
employer:___________________________________________________________________
Phone: (____) _____-__________
Do we have permission to contact your
employer? Yes
No
Do you have previous EMS experience? Yes
No
If yes, please complete the next section.
Agency:___________________________________ Date of
service:_____________ to ____________
Position: __________________________________
Reason for leaving: _________________________
Supervisors
Name: _____________________________________________
Agency:___________________________________ Date of
service:_____________ to ____________
Position: __________________________________ Reason for leaving: _________________________
Supervisors
Name: _____________________________________________
Personal
References (3
REQUIRED, not family):
Reference
#1:
Name: ____________________________
Phone #: (____) ____-______
E-Mail:_______________
Street address:_____________________________ City: ___________________ State: ___ Zip: _____
Years Known:______ Relationship:________________________________________________________
Best time to
contact: ___________________________________________________________________
Reference
#2:
Name: ____________________________
Phone #: (____) ____-______
E-Mail:_______________
Street address:_____________________________ City: ___________________ State: ___ Zip: _____
Years Known:______ Relationship:________________________________________________________
Best time to
contact: ___________________________________________________________________
Reference
#3:
Name: ____________________________
Phone #: (____) ____-______
E-Mail:_______________
Street address:_____________________________ City: ___________________ State: ___ Zip: _____
Years Known:______ Relationship:________________________________________________________
Best time to
contact: ___________________________________________________________________
Emergency
Contacts:
Name: ______________________________________ Home Phone: (_____) _____-________
Work Phone: (_____) _____-________ E-Mail:___________________@_____________________
Pager: (_____)
_____-________
Other Phone: (_____)
_____-________
Street address:_____________________________ City: ___________________ State: ___ Zip: _____
Relationship:__________________________________________________________________________
Name: ______________________________________ Home
Phone: (_____)
_____-________
Work Phone: (_____) _____-________ E-Mail:___________________@_____________________
Pager: (_____)
_____-________
Other Phone: (_____)
_____-________
Street address:_____________________________ City: ___________________ State: ___ Zip: ______
Relationship:__________________________________________________________________________
I _______________________certify that all
the foregoing information is a complete and accurate statement of
the facts and understand that if any misrepresentation, omission, or
falsification be discovered, it will constitute grounds for
immediate dismissal. I hereby authorize you to conduct any
investigation necessary concerning any part of my background related
to the position I am seeking. I release all parties from liability
in connection with the provision and use of such information.
I understand and agree that, if I become a
member of this organization, I will abide by its rules and
regulations, which I understand, are subject to change.
ð I accept ð I decline
________________________________________________ ____/____/________
Sign Here Date
