PLEASANTVILLE VOLUNTEER AMBULANCE CORPS
MEMBERSHIP APPLICATION
Personal Information
Name:
Date of Birth: / / (MM/DD/YYYY)
Street Address:
City, State, Zip:
Home Phone:
Cell Phone:
Email:

Current Employer
Name:
Phone:
Address:

Membership Status Requesting
Aider Driver EMT Youth Corps

Certifications
Please check all that apply:

CPR Exp. Date
First Aid/CFR Exp. Date
EMT-B Exp. Date
Exp. Date

Emergency Contacts
Name: Relationship: Phone:
Name: Relationship: Phone:

Have you ever been convicted of a felony or misdemeanor or currently under investigation for any criminal acts? Yes No
If Yes, please explain:
 
Have you ever been discharged for misconduct or unsatisfactory service or asked to resign from any Emergency Service agency? Yes No
If Yes, please explain:

Personal References
Please list three (3) personal references below. One reference should be in a supervisory position.

Name Relationship
Address Phone
 
Name Relationship
Address Phone
 
Name Relationship
Address Phone
 

Attestation
By submitting this form, I attest that the statements made on this application are true and I understand that all information provided is subject to verification. Any false information provided on this application may disqualify me as a potential member of the Pleasantville Volunteer Ambulance Corps.

Applicants under the age of 18 require a parent or guardian's permission prior to acceptance.