Online Application

All questions must be answered. If a question does not apply to you or you do not know the answer, type "N/A" or "Unknown."

Name *
Name
Date of Birth *
Date of Birth
Contact Information
Address *
Address
Home
Home
Mobile
Mobile
FLVAC Affiliation
Are you related to anyone affiliated with the FLVAC? *
Have you previously applied to the FLVAC? *
If yes, when?
If yes, when?
Have you previously been a member of the FLVAC? *
If yes, when?
If yes, when?
EMS Experience
Have you ever been a member or employee of an EMS agency? *
Ambulance Corps, First Aid Squad, Hospital EMS, Rescue Squad, etc.
If yes, please list affilations below
Background Information
Have you ever been convicted of a crime? *
Misdemeanors, felonies, etc.
Do you possess a valid US driver's license? *
Have you ever had your license suspended?
Are you legally permitted to obtain employment in the United States? *
Education
Level of Education Completed
Check all that apply.
Date Enrolled
Date Enrolled
Date Graduated
Date Graduated
Date Enrolled
Date Enrolled
Date Graduated
Date Graduated
Date Enrolled
Date Enrolled
Date Graduated
Date Graduated
Employment History
Certifications
New Jersey Emergency Medical Technician (EMT) License *
State of New Jersey Department of Health | Office of Emergency Medical Services
Anticipated Completion Date
Anticipated Completion Date
If currently enrolled in New Jersey EMT Training Course
Certification Date
Certification Date
Expiration Date
Expiration Date
Cardiopulmonary Resuscitation (CPR) Certification *
Certification Date
Certification Date
Expiration Date
Expiration Date
The following certifications are not required for the application
CEVO Certification Date
CEVO Certification Date
FEMA ICS-100 Certification Date
FEMA ICS-100 Certification Date
FEMA ICS-200 Certification Date
FEMA ICS-200 Certification Date
FEMA ICS-700/NIMS Certification Date
FEMA ICS-700/NIMS Certification Date
FEMA ICS-800/NIMS Certification Date
FEMA ICS-800/NIMS Certification Date
Hazardous Materials Awareness Certification Date
Hazardous Materials Awareness Certification Date
Blood Borne Pathogens Certification Date
Blood Borne Pathogens Certification Date
References
Two references are required. Only one may be a personal reference.
Reference 1
Reference 1
Address
Address
Phone
Phone
Type of Reference
Reference 2
Reference 2
Address
Address
Phone
Phone
Type of Reference
Conclusion
Terms & Conditions
If this application is accepted, I hereby agree to comply with all rules and regulations of the Fort Lee Volunteer Ambulance Corps, Inc. Furthermore, I understand that I will be a probationary member for a minimum of 9 months and a maximum of 12 months from the date of my acceptance. During that time period, I agree to rotate my shifts/schedule at the Corps and ride with a variety of Crew Chiefs who will evaluate my skills and complete my Skills Checklist. I understand that failure to be flexible with the scheduling of my shifts may result in extension of my probationary period, failure to obtain status of Regular Member within the Corps, and/or dismissal. Furthermore, I hereby agree to submit to a physical examination by a licensed healthcare provider (MD, DO, NP or PA). Documentation of this examination on the approved FLVAC Medical Evaluation Form is to be submitted prior to the screening interview. In addition, I hereby grant the Fort Lee Police Department permission to perform a criminal history background check and driving history check on me. Finally, I hereby agree that the information provided on this application has been provided by me and is true to the best of my knowledge. I understand that any false information or statements on this application or on the Medical Evaluation Form is sufficient cause for rejection of this application and/or dismissal from the FLVAC.
Application Date *
Application Date
Application Time *
Application Time

Additional Information

Upon submission, your application will be reviewed, and you will be contacted within several weeks to schedule an interview. You must bring all required forms and copies of your Emergency Medical Technician license, Healthcare Provider CPR certification, and driver's license, if applicable. Failure to complete and submit required forms may cause unnecessary delay in processing your application. 

Please note that all members are required to work a minimum of nine (9) shifts with a minimum of three (3) weekend shifts during each operational quarter. Failure to meet the minimum shift requirements is grounds for dismissal from the agency. Applicants should review and familiarize themselves with the shift times shown below.


Required Forms

In addition to the online application, the following forms are required for all applicants. Please print out and complete all of the following forms and bring them to the screening interview. Electronic submissions will not be accepted.