LAKELAND EMERGENCY SQUAD APPLICATION FOR MEMBERSHIP
Please answer all questions as best as you can. If a question does not pertain to you, or you are unable to answer it, please type N/A for your response. Once everything is filled out, hit the submit button and a representative from the squad will be in contact with you shortly. *This application is subject to review and investigation by the Membership Committee of the Lakeland Emergency Squad, Inc. Once an interview has been scheduled, please provide a photocopy of your NJ Driver's License and any EMT, First Aid, or CPR cards you may hold at the time of the time of the scheduled interview.
Name *
Your answer
Application Date *
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Address *
Your answer
Number of Years at Address *
Your answer
Date of birth *
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Home Phone *
Your answer
Cell Phone and Carrier *
Your answer
Driver's License Number (Include State Issued and Expiration Date) *
Your answer
Email *
Your answer
Employer *
Your answer
Occupation *
Your answer
Address of Employer *
Your answer
Number of Years at Job *
Your answer
List Any Certifications Currently Held and their Expiration Date *
Your answer
Have you ever been a member of a first aid/ rescue squad or fire department? *
If answer to above question is YES, please list the name of the agency and reason for leaving *
Your answer
Have you ever been convicted of, or pled guilty to: a disorderly persons offense, a crime, or a D.W.I. charge? *
If answer to the above question is YES, please list jurisdiction(s), date(s), and penalties *
Your answer
Reference 1- Non-relative and non-member. Please include: name, address, phone number, and years known *
Your answer
Reference 2- Non-relative and non-member. Please include: name, address, phone number, and years known *
Your answer
By checking this box, you certify that all above information provided is accurate to your knowledge. *
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