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Ramapo Valley Ambulance Corps
Application for Membership
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone Number
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Training & Experience, (please check off all that apply))
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Possession of current CPR certification
Possession of a current NYS EMT certification
You are or have been an emergency services volunteer
Possession of any other medical training not mentioned above
If yes to the above, (medical or other experience) please specify
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Do you have any medical Conditions that might preclude you from working on an ambulance?
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No
Yes
If yes, please specify
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Have you ever been convicted of a criminal offense?
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No
Yes
If yes, please specify
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Please list any driving violations that you have been convicted of in the last 10 years
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Current occupation and years at current employment
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Current employers name
*
Phone Number of Current Employer
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Location of Current Employer (city and state)
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Name of Previous Employer and Years at Employment
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Phone Number of Previous Employer
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Location of Previous Employer (city and state)
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Reason for leaving
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References - please provide three character references. Do not list family members. Reference #1
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First
Last
Phone Number
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Relationship and Years Known
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Reference #2
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First
Last
Phone Number
*
-
-
Relationship and Years Known
*
Reference #3
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First
Last
Phone Number
*
-
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Relationship and Years Known
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How did you hear about RVAC?
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Please write a few short sentences explaining your reasons for joining RVAC
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Please upload a copy of your Drivers licence and all other applicable certifications
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Max file size: 20MB
I hereby pledge that the information provided on this application is true to the best of my knowledge. If accepted as a member of Ramapo Valley Ambulance Corps, Inc. I shall abide by its by-laws and serve the Corps to the best of my professional ability.
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I Agree
Submit