Membership Application

Application for Membership

PLEASE FILL OUT COMPLETELY YOU ARE ON A SECURE SERVER YOUR INFORMATION WILL NOT BE SHARED.

Please read our Privacy Policy and our Terms & Conditions.

* Required

Your Information Is Safe and Will Not Be Shared.

Personal Information

Applicant's First Name*

Applicant's Middle Initial

Applicant's Last Name*

Date of Birth*

Address 1*

Address 2

Town/City*

State*

Zip Code*

How long have you lived at that address ?*

Contact Information

Email Address*

Home Phone

Cell Phone*

Best Way to Contact You*

Emergency Contact*

Emergency Contact Phone Number*

Relationship to Applicant*

Drivers License Number or State ID (If Applicable)

Expiration Date

State

Position Desired

(These selections are NOT binding; they are to indicate your interests.)

Position Desired*

How Did You Hear About Us

When Are You Available to Volunteer?*

Have you previously applied to Bay Community Volunteer Ambulance?*

Have you ever been a member of any Emergency Service Agency

If Yes: Please Provide The Agency Name, Address, Phone and Contact

Are you still with this/these agency/agencies?*

If No, please provide approximate date you left

Please list any past or present Emergency Service certifications held

Please list any other special skills or interests you may have

Miscilanious Information

Misc Info

Do you have any physical, mental, or psychological impairment or disability that would interfere with the performance of your duties as Dispatcher, EMT, EMT Driver or Office?*

If you Answered Yes

Have you ever been convicted or plead guilty to a felony, a misdemeanor, or a reduction of one of these offenses?*

*If ‘Yes’ to the question above please give details below:

Disclaimer

All information contained and/or obtained herein will remain confidential and will be used only for internal membership processing. By signing this application, I hereby state that all questions have been answered truthfully and without omission, and I further authorize the Membership Committee or officers of College Point Community Ambulance Corps to verify all of the above statements by any means including a criminal background check. I also understand that willful falsification or omission from this application will subject it to immediate rejection. If accepted as a member and information in this application is found to be inaccurate or incomplete, I could be subject to disciplinary action or expulsion.

Acceptance or rejection of an applicant is solely at the discretion of the Membership Committee or officers of College Point Community Ambulance Corps. The decision is final with no explanation provided. It is further understood that College Point Community Ambulance Corps does not discriminate due to age, sex, race, religion, creed, national origin or sexual orientation. If accepted as a member of College Point Community Volunteer Ambulance, I understand that I must abide by the rules and regulations of the Corporation or my membership may be terminated.

Please Provide 3 References that are not related to you.

Reference 1

Full Name*

Relationship to applicant*

Phone Number*

Best Time To Call*

Reference 2

Full Name*

Relationship to applicant*

Phone Number*

Best Time To Call*

Reference 3

Full Name*

Relationship to applicant*

Phone Number*

Best Time To Call*

Signature*

Please Choose Todays Date*

Please Print Your name*

Thank You For Your Submission.

Become a Member

Application for Membership

Position Desired

Miscilanious Information

Please Provide 3 References that are not related to you.

Reference 1

Reference 2

Reference 3

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