Application for Membership
Membership Application
Name: _________________________ Date Of Birth:___________
Address: ______________________________________________
Home Phone Number: __________ Cell Phone Number: _________
E-Mail Address: _________________________________________
Social Security Number: ____________________
Drivers License Number: ____________ Exp. Date: __________
Emergency Notification: _________________ Relation: ___________
Address: ______________________________________________
Home Phone Number: ________ Cell Phone Number: __________
References
1) Name: ______________________ Phone Number: ___________
Known how long: ____________
2) Name: ______________________ Phone Number: __________
Known how long: ____________
3) Name: ______________________ Phone Number: ____________
Known how long: ____________
Employment History
1) Name of Employer: _____________________________________
Job Title: ____________________________________________
Supervisor: ___________________________________________
Phone Number for employer: _____________________________
How long have you been employed and reason for leaving (if applicable):
_____________________________________________________
2) Name of Employer: _____________________________________
Job Title: _____________________________________________
Supervisor: ____________________________________________
Phone Number for employer: ______________________________
How long have you been employed and reason for leaving (if applicable):
____________________________________________________
3) Name of Employer: ____________________________________
Job Title: ___________________________________________
Supervisor: __________________________________________
Phone Number for employer: ____________________________
How long have you been employed and reason for leaving (if applicable):
____________________________________________________
4) Name of Employer: ____________________________________
Job Title: ___________________________________________
Supervisor: _________________________________________
Phone Number for employer: ___________________________
How long have you been employed and reason for leaving (if applicable):
__________________________________________________
Questionnaire
Type of membership applying for: EVO or EMS Provider
Active or Reserve
1) Do you now have any physical, mental, emotional or nervous conditions, diseases or disabilities that may affect your ability to perform duties in this rescue squad?
NO YES Explain: _______________________________
2) Have you ever been convicted of any crimes (Felony, Misdemeanor or Violation)?
NO YES Explain: ______________________________
3) Do you have any pending criminal court cases?
NO YES Explain: ______________________________
4) Do you have any points on your driving record:
NO YES Explain: ______________________________
5) Are you now or have you ever been a member of another EMS/Fire Agency?
NO YES Which Ones: __________________________
6) Do you hold any NYS DOH EMS certificates?
NO YES Which Ones: _________________________
7) Which EMS courses would you like to take?
CFR EMT AEMT
Do you possess any skills that would be helpful to this organization?
__________________________________________________
PLEASE READ:
The Bay Ridge Rescue Squad Inc. prides itself on accepting applications for membership regardless of an applicant’s race, color, creed, sex, marital status, disability, national origin, ancestry or place of birth.
I hereby apply for membership in the Bay Ridge Rescue Squad Inc., I understand that my acceptance in the corporation will be on a six month probationary basis. During which time my membership may be terminated in accordance with the corporation by-laws. Any false statements or omissions made in this application will be considered sufficient cause for expulsion from the corporation upon discovery thereof.
I hereby authorize Bay Ridge Rescue Squad Inc., or its representatives to make official inquiry of all persons, public and private companies, corporations, consumer reporting agencies, law enforcement agencies, state licensing and certifying agencies and medical advisors of this corporation to supply all information concerning my character, current and prior employment or membership verification, general reputation, personal characteristics and mode of living, and furnish reports thereon.
I accepted into the membership of the Bay Ridge Rescue Squad Inc., I will follow the operating rules as adopted and the by-laws as they may be amended in the future. I will agree to submit to physical and medical examinations at the option and expense of the corporation and also agree that the examining physician will disclose to the corporation or its representatives, the results of such examinations.
Signature: _____________ Date: _____________
DISCLOSURE AND RELEASE
In connection with my application for membership or employment (including contract for services) with the Bay Ridge Rescue Squad Inc., I understand that consumer reports, which may contain public record information, may be requested and obtained. These reports may include information related to my previous driving record including court actions, citations, license suspensions and revocations.
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED TO FURNISH THE ABOVE MENTIONED INFORMATION.
I have the right to obtain information as to the name, address and phone number of any agency providing such information and further, may request of that agency, upon proper identification, the nature and substance of all information in its files on me at the time of my request, including all sources of information as well as the recipients of any reports on me which that agency has previously furnished within the two (2) year period preceding my request.
This authorization shall remain on file and shall serve as ongoing authorization for the organization to procure Motor Vehicle Reports at any time during my employment, membership or contract period.
_________________________ ______________
Signature Date