Tri-Boro Volunteer Ambulance Corps
Membership Application

If you are over 18 years of age, you may complete and mail this form to Tri-Boro Volunteer Ambulance Corp., P.O. Box 204, Park Ridge, N.J. 07656. If you are under the age of 18 you must obtain your parents signature.

Regardless of the form you submit, all fields (*) must be completed, or it cannot be accepted. Once we receive your application, a member of the Corps will contact you to schedule an interview.

Information provided to be verified by the Tri-Boro Volunteer Ambulance Corps.
 
Last Name*:_________________  First Name*: _________________  Middle: _______
Address*: _______________________________________________________________
Town*:_________________________________
Home Telephone*:  (______) ______-________  Work Telephone:  (______) ______-________
Pager:  (______) ______-________  Mobile:  (______) ______-________
E-mail:  ____________________________
 
Age*:  ______  Date of Birth*:  ___/___/_____  Sex* (check one):  Male   Female
Social Security #*:  ______-_____-_______
 
Length of time residing and/or employed in Tri-Boro area*:   ____________________
Current Occupation*:   _____________________________________________
Employer*:  ________________________  Address*:  ___________________________________
 
Highest Level of Education*:  High School  College  Other  _____________________
 
Referred to Tri-Boro Volunteer
Ambulance Corps by (if applicable):  _____________________________________________
 
Do you have a driver's license?*   Yes  No
D/L#:   _______________________  State:   ________  Expiration Date:   _________________
 
Has your driver's license ever been
suspended or revoked for ANY reason?   Yes   No
If yes, please explain and give dates:  ____________________________________________________

Have you ever been convicted of a crime?*   Yes   No
If yes, please explain and give dates:  ___________________________________________________

Have you ever applied for membership to
the Tri-Boro Volunteer Ambulance Corps?*   Yes   No
If yes, list dates:  _______________________________________________

Have you ever been a member of the
Tri-Boro Volunteer Ambulance Corps in the past?*   Yes   No
If yes, when: ___________  Reason for Leaving:______________________________________
 
Have you ever applied to and/or been a member to another ambulance corps or
first aid squad (volunteer/paid)?*   Yes   No
If yes, complete the following:

(Please attach separate sheet if affiliated with more than three organizations.)
 
 
Have you ever had any first aid and/or
emergency medical services training?*   Yes   No
If yes, please list course(s) and expiration date below.

Please include copies of all certifications with application
 
AVAILABILITY (Please check below days & times available)

If acceptance is granted under this application, I do understand and agree to comply with all the rules and regulations, which includes but not limited to the By-Laws and Operational Guidelines of the Tri-Boro Volunteer Ambulance Corps. I further agree to submit documentation of a physical examination by a licensed healthcare provider (MD, DO, NP) prior to duty assignment. (Physical examination documentation form provided by the Tri-Boro Volunteer Ambulance Corps.) In addition, I give the Park Ridge Police Department permission to perform a background investigation on me.

The information provided on this application has been provided by me and are true to the best of my knowledge. It is understood that any false information or statements on this application or on the physical examination documentation, is sufficient cause for rejection of this application and/or dismissal from the Tri-Boro Volunteer Ambulance Corps.
 
Signature:___________________________________ Date: ___________

Signature:___________________________________ Date: ___________
(If a minor, parent/guardian signature required)
 
DO NOT WRITE BELOW THIS LINE

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Date Application Received: _______________________________________

Date Interviewed: ______________________________

Interviewed by: ________________, ________________, ________________

Application reviewed by:  Captain   President     Application Committee

Date accepted as member: _________  Membership Type (initial):___________________________

Membership information provided to:  Scheduling Officer   Training Officer     Secretary

Date resigned/terminated: _________  Reason:_____________ _________________________

Did member resign in good standing:  Yes   No    If no, please provide documentation.