Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Date of Birth
*
MM
DD
YYYY
Mobile Phone
*
(###)
###
####
Years at Current Address
*
(If less than 7 years, list previous address)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Are you currently certified as an EMT or higher?
*
If yes, level:
Expiration:
MM
DD
YYYY
State:
New York - NY
Alabama - AL
Alaska - AK
Arizona - AZ
Arkansas - AR
California - CA
Colorado - CO
Connecticut - CT
Delaware - DE
Florida - FL
Georgia - GA
Hawaii - HI
Idaho - ID
Illinois - IL
Indiana - IN
Iowa - IA
Kansas - KS
Kentucky - KY
Louisiana - LA
Maine - ME
Maryland - MD
Massachusetts - MA
Michigan - MI
Minnesota - MN
Mississippi - MS
Missouri - MO
Montana - MT
Nebraska - NE
Nevada - NV
New Hampshire - NH
New Jersey - NJ
New Mexico - NM
New York - NY
North Carolina - NC
North Dakota - ND
Ohio - OH
Oklahoma - OK
Oregon - OR
Pennsylvania - PA
Rhode Island - RI
South Carolina - SC
South Dakota - SD
Tennessee - TN
Texas - TX
Utah - UT
Vermont - VT
Virginia - VA
Washington - WA
West Virginia - WV
Wisconsin - WI
Wyoming - WY
Certification No.:
Has your certification ever been revoked or suspended for any reason?
If "YES", please explain date(s) and reason(s) for the revocation and/or suspension:
List any certifications past and present including NREMT certifications, ACLS, BCLS, PALS, CPR, PHTLS, Etc.… (Include expiration dates and copies of current certifications will need to be submitted upon request):
Do you currently have a valid Driver’s License?
*
Driver's License Number:
Driver's License State:
NY
AK
AL
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Other
Driver's License Class:
A
B
C
D
DJ
E
M
MJ
Driver's License Expiration Date:
*
MM
DD
YYYY
How many years have you had your license?
Have you ever had a driver’s license suspended or revoked?
If Yes, please explain the suspension and/or revocation:
Have you any summons for traffic violations within the past three years?
*
If Yes, please explain the traffic violation:
Except for the above traffic offenses, have you ever been (YES/NO) Convicted of any violation, misdemeanor, or felony?
*
If Yes, please explain the conviction of any violation, misdemeanor, or felony:
Are there any criminal charges pending against you at this time?
*
If Yes, please explain the criminal charges pending against you at this time:
Were you ever dismissed from employment for reasons other than reduction in staff?
*
If Yes, please explain the reason for dismissal:
Please select highest level of education completed:
*
Start Date
*
MM
DD
YYYY
Graduation Date
*
MM
DD
YYYY
Name of Employer
*
Address of Employment
Phone Number & Extension
Start Date
*
MM
DD
YYYY
End Date
if current employer, leave blank
MM
DD
YYYY
Position Held
Name of Supervisor
Title of Supervisor
Briefly describe the work you perform:
May we contact this employer?
If no, please explain why
Name of Employer
Address of Employment
Phone Number & Extension
Start Date
MM
DD
YYYY
End Date
if current employer, leave blank
MM
DD
YYYY
Position Held
Name of Supervisor
Title of Supervisor
Briefly describe the work you performed:
May we contact this employer?
If no, please explain why
Name of Employer
Address of Employment
Phone Number & Extension
Start Date
MM
DD
YYYY
End Date
if current employer, leave blank
MM
DD
YYYY
Position Held
Name of Supervisor
Title of Supervisor
Briefly describe the work you performed:
May we contact this employer?
If no, please explain why
Reference 1 Name
*
First Name
Last Name
Reference 1 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Reference 1 Phone
*
(###)
###
####
Reference 1 Email
Relation to applicant:
*
Years known applicant:
*
Reference 2 Name
*
First Name
Last Name
Reference 2 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Reference 2 Phone
*
(###)
###
####
Reference 2 Email
Relation to applicant:
*
Years known applicant:
*
Reference 3 Name
*
First Name
Last Name
Reference 3 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Reference 3 Phone
*
(###)
###
####
Reference 3 Email
Relation to applicant:
*
Years known applicant:
*
Reference 4 Name
*
First Name
Last Name
Reference 4 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Reference 4 Phone
*
(###)
###
####
Reference 4 Email
Relation to applicant:
*
Years known applicant:
*
Are you currently or have ever been a member of a volunteer EMS agency, Fire Department, Auxiliary Police Department, or any other Public Safety Organization?
*
If “YES”, please list ALL Departments and associated information below, including a reason for leaving.
Department Name | Title/Position | Start Date | End Date | Reason for Leaving
Are you currently or have ever been a member of a Paid Professional EMS agency, Fire Department, Auxiliary Police Department, or any other Public Safety Organization?
*
If “YES”, please list ALL Departments and associated information below, including a reason for leaving.
Department Name | Title/Position | Start Date | End Date | Reason for Leaving
Have you ever previously applied for membership with The City of Glen Cove Volunteer EMS?
*
If yes, please specify date of most recent application submitted:
MM
DD
YYYY
Have you ever been denied membership to any EMS agency, Fire Department, Auxiliary Police Department, or Public Safety Organization?
*
If yes, please specify:
Have you ever been suspended, returned to probationary status, terminated or been asked to resign from any EMS agency, Fire Department, Auxiliary Police Department, or Public Safety Organization?
*
If yes, specify departments and dates, and include the reason for termination:
I,
*
First Name
Last Name
do hereby authorize release, to the City of Glen Cove Volunteer Emergency Medical Services Corps. release of my personal documents and recordings including, but not limited to, the following: employment, motor vehicle, criminal history, taxing authorities, armed services, credit bureaus, government agencies, medical-hospital, school, and probation/parole. I agree to waive all privileges arising out of the confidential nature of such records and to release any entity providing such records, its employees and all agents from any and all actions, causes of action and liability whatsoever to me, or to my heirs or assigns forever, arising from the furnishing of such information. I have read and fully understand the contents of this “Authorization for Release of Personal Information”. I affirm under penalties of perjury that all statements made on this application supplement are true. A PHOTOCOPY/ FACSIMILE OF THIS RELEASE WILL BE VALID AS AN ORIGINAL THEREOF, EVEN THOUGH THE SAID PHOTOCOPY/FACSIMILE DOES NOT CONTAIN AN ORIGINAL WRITING OF MY SIGNATURE.
*
First Name
Last Name
Today's Date
*
MM
DD
YYYY
I,
*
First Name
Last Name
agree that, if accepted as a member of the Glen Cove Volunteer Emergency Medical Services Corps. I will abide by its’ Constitution, By-Laws, Policies & Procedures. I understand that once accepted as a member, I must pass a physical within 3 months of being accepted to become an active member. I agree to attend any necessary training for probationary members. I understand that the first six (6) months of membership are probationary (and may be extended in just cause). I understand that violation of the Corps. rules during probation may subject me to dismissal from the Corps.
*
Today's Date
*
MM
DD
YYYY