Membership Application

Personal Information

Name:

Email Address:

Street Address:

House Number:

City + State:

Zip Code:

How long have you lived at this address?

Phone number:

Cell phone number:

Date of birth:

Age:

Sex:MaleFemale

Social Security Number:

Emergency Contact

Emergency Contact Name:

Emergency Contact phone Number:

Emergency Contact Relationship:

Emergency Contact Street Address:

Emergency Contact House Number:

Emergency Contact City + State:

Emergency Contact Zip Code:

Education & Training

Grade Completed:

High School Name:

City:

State:

Date Graduated or GED:Colleges or Universities Attended (Include dates):

Training Certifications

EMT Certification Number:

State:

Expiration Date:

National Certification:YesNo

National Certification Number:

CPR Certification Type/Level:

CPR Expiration Date:

Other Training:

Driving Record

(Please note you must provide a NJ Motor Vehicles Drivers Abstract Upon Acceptance into the Squad)

State:

License Class:

Drivers License Number:

Restrictions:

Points Against:

Has Your Driving Privilege Ever Been Suspended or Revoked?:

YesNo

If Yes, Please Explain:

Disabilities

Do You Have Any Psychological or Physical Disabilities That May Prevent You From Performing Your Duties As A First Responder?

YesNo

If Yes, Please Explain:

Employment History

Current Employer:

Dates:

Supervisor:

Contact Phone Number for Reference:

Address:

Position:

Reason for Leaving:

Most Recent Previous Employer:

Dates:

Supervisor:

Contact Phone Number for Reference:

Address:

Position:

Reason for Leaving:

Nottingham Ambulance Squad may contact any of the above supervisors for references.

Personal References

Name Reference 1:

Phone Number:

Occupation/Relationship:

Name Reference 2:

Phone Number:

Occupation/Relationship:

Name Reference 3:

Phone Number:

Occupation/Relationship:

General Information

Have You Ever Been Convicted, Fined, Placed On Probation, Or Imprisoned For Any Criminal Offense?

YesNo

If Yes, Please Explain:Have You Ever Been Dismissed Or Asked To Resign From Any Position?

YesNo

If Yes, Please Explain:Have You Ever Been An Applicant Or Member Of A Volunteer Fire Department Or Ambulance Squad?

YesNo

Department Or Squad 1:

Dates:

Address:

Supervisor:

Department Or Squad 2:

Dates:

Address:

Supervisor:

Have You Ever Been Asked To Resign Or Expelled From A Volunteer Fire Department Or Ambulance Squad?

YesNo

If Yes, Please Explain:

General Information

I, the undersigned, certify that I have read and fully understand this form in its entirety and that the information herein provided is true and accurate to the best of my knowledge. I understand that should any statement I have made prove to be false, misleading, or erroneous it may result in the rejection or in my discharge from the Nottingham Ambulance Squad Inc.

By signing below, I herby authorize the Nottingham Ambulance Squad and its officers or delegates to conduct the background checks necessary to verify that the above information is correct and accurate. I further agree that, if granted membership, I will uphold the rules, regulations and by-laws of the Nottingham Ambulance Squad, Inc.

Thank you for your request! We will get back in touch as soon as possible.

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