Membership Application

 

PART A - PERSONAL INFORMATION



Last Name
First Name
Address
City, State, Zip
Phone Number
E-mail Address
Date of Birth




PART B - PRE-HOSPITAL TRAINING

Please Check your current level of training

None
CPR, AED Training / Certification
CFR-D
EMT-B
EMT-CC
EMT-P

State of Certification
Certificate #
Expiration Date

Dates School Certification




PART C - EDUCATION

Please list all schools attended

Dates School Diploma/Degree




PART D - EMPLOYMENT HISTORY

Please list all employment beginning with most recent

Dates Employer Title




PART E - RESCUE/VOLUNTEER EXPERIENCE

Dates Department




PART F - REFERENCES

Please list 3 references that you have known for at least 3 years. Relatives and members of the Mineola Volunteer Ambulance Corps are not acceptable references.

Name
Address
City, State, Zip
Phone Number


Name
Address
City, State, Zip
Phone Number


Name
Address
City, State, Zip
Phone Number




PART G - Questionnaire

Please answer the following questions

YES NO
Do you plan to or are you currently applying to any health related school or program (medical school, nursing school, PA school...)?
Do you waive review of your references?
Do you currently have a valid drivers license?

State: License # exp:


If your answer is YES to any of the following questions, please give a brief explanation below.

YES NO
Have you ever been convicted of a felony or misdemeanor?
Have you ever been convicted of DWUI?
Have you ever been convicted of DWI?
Have you ever been fired/dismissed/asked to resign from any employment and/or volunteer agency?
Have you ever or do you currenty serve in the military?
If yes to above, was your discharge other than honorable?
Is there a physical/mental condition that would interfere with your duties as a member of the Mineola Volunteer Ambulance Corps?




PART H - Affidavit


Please read before submitting


In submitting my application to the Mineola Volunteer Ambulance Corps Inc., I understand that the Mineola Volunteer Ambulance Corps Inc., its officers, members and/or agents will be conducting a background check and character investigation as to my suitablity as a member. I give my complete authorization to the Mineola Volunteer Ambulance Corps Inc., its officers, members and/or agents to conduct this check. I understand this background check will include verification of employment history, past/present membership in any volunteer organizations and character references. This authorization will remain in effect until cancelled by me in writing. Furthermore, I attest that the answers supplied on this application are true and that false statements may be the basis for dismissal from the Mineola Volunteer Ambulance Corps Inc.


** note: you will be asked to sign a copy of this affidavit at the time of interview **