Name *

As appeared on your legal form of identification

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home

(###)

###

####

Mobile *

(###)

###

####

Are you related to any member of the Fort Lee Volunteer Ambulance Corps? *

Yes

No

Have you previously applied to the Fort Lee Volunteer Ambulance Corps? *

Yes

No

If yes, when?

MM

DD

YYYY

Have you previously been a member of the Fort Lee Volunteer Ambulance Corps? *

Yes

No

If yes, when?

MM

DD

YYYY

Have you ever been a member or employee of an EMS agency? *

Ambulance Corps, First Aid Squad, Hospital EMS, Rescue Squad, etc.

Yes

No

Have you ever been convicted of a crime? *

Misdemeanors, felonies, etc.

Yes

No

Do you possess a valid US driver's license? *

Yes

No

Have you ever had your license suspended?

Yes

No

Are you legally permitted to obtain employment in the United States? *

Yes

No

Level of Education Completed

Check all that apply.

High School / G.E.D.

Some College

Associate's Degree

Bachelor's Degree

Master's Degree

Doctorate's Degree

Date Enrolled

MM

DD

YYYY

Date Graduated / Expected Graduation Date

MM

DD

YYYY

Date Enrolled

MM

DD

YYYY

Date Graduated / Expected Graduation Date

MM

DD

YYYY

Date Enrolled

MM

DD

YYYY

Date Graduated / Expected Graduation Date

MM

DD

YYYY

May we contact your employers?

Yes

No

Emergency Medical Technician (EMT) License *

State of New Jersey Department of Health | Office of Emergency Medical Services -or- National Registry of Emergency Medical Technicians

Yes

No

In Progress

Anticipated Completion Date (if you answered "No" to above)

If currently enrolled in EMT Training Course

MM

DD

YYYY

Certification Date

MM

DD

YYYY

Expiration Date

MM

DD

YYYY

Cardiopulmonary Resuscitation (CPR) Certification *

Yes

No

Certification Date

MM

DD

YYYY

Expiration Date

MM

DD

YYYY

Have you received American Red Cross Basic Life Support CPR certification?

Yes

No

Have you received American Heart Association Healthcare Provider CPR certification?

Yes

No

CEVO Certification Date

MM

DD

YYYY

FEMA ICS-100 Certification Date

MM

DD

YYYY

FEMA ICS-200 Certification Date

MM

DD

YYYY

FEMA ICS-700/NIMS Certification Date

MM

DD

YYYY

FEMA ICS-800/NIMS Certification Date

MM

DD

YYYY

Hazardous Materials Awareness Certification Date

MM

DD

YYYY

Blood Borne Pathogens Certification Date

MM

DD

YYYY

Reference 1 *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Type of Reference *

Academic

Employment

Personal

Reference 2 *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Type of Reference *

Academic

Employment

Application Date *

MM

DD

YYYY