Lambertville - New Hope Ambulance & Rescue Squad Online Application
Email address *
First and Last Name (Legal Name) *
Your answer
Address (Please No PO boxes) *
Please list full address including Street, City, State and Zip Code
Your answer
Phone Number (XXX)XXX-XXXX *
Your answer
Date of Birth *
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Membership Category *
Are you authorized to work in the U.S.? *
Have you ever been, applied to, or are a current member of any other Emergency Services Department (EMS, Rescue or Fire), paid or volunteer? * *
If yes, please list all agencies, and the timeframe of which you were involved with each agency. *
Your answer
1. Have you ever been arrested? *
2. Have you ever been convicted of a felony? *
3. Have you ever been convicted of any crime or any municipal offense? *
4. Have you ever pled guilty to any crime or any municipal offense? *
5. Have you ever been accused of or charged with an incident of domestic violence or domestic disturbance? *
6. Have you ever had a criminal record expunged, or been accepted into a Pre-Trial Intervention or Conditional Discharge or Diversion Program? *
7. Have you ever been charged with Driving while intoxicated or Driving under the influence? *
8. Have you ever received a summons complaint or been indicted for any violation of the law? *
9. Has any business concern you owned or controlled received a summons complaint or been indicted for any violation of the law? *
If you answered yes to any of the question 1-9 please provide a detailed description of each below. *
Your answer
Do you have a valid driver's license? *
Drivers license Issuing State
Drivers License Number
Your answer
Is your driving privilege revoked in any state? *
What is your highest level of education? *
Your answer
Please list any emergency services training or certifications that you have or have completed. *
Your answer
Reference 1 Name and Relation *
Your answer
Reference 1 Phone Number (XXX)XXX-XXXX *
Your answer
Reference 2 Name and Relation *
Your answer
Reference 2 Phone Number (XXX)XXX-XXXX *
Your answer
Reference 3 Name and Relation *
Your answer
Reference 3 Phone Number (XXX)XXX-XXXX *
Your answer
Employment History *
Please list last 3 employers, including Name, phone number, job title, supervisor and reason for leaving.
Your answer
Have you ever been in the military? *
Please list Branch, years of service, rank at discharge and type of discharge. *
Your answer
In connection with my application for membership or employment (including contract for services) with the Lambertville - New Hope Ambulance & Rescue Squad, I understand that consumer reports and/or criminal background records, which may contain public record information, may be requested and obtained. These reports may include information related to my criminal record and 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 criminal background information and Motor Vehicle Reports at any time during my employment, membership or contract period. Please type your name below as a digital signature to this statement. *
Your answer
Please list Full Legal Name, maiden name or any aliases used. *
Your answer
I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in my application or interview may result in my rejection or dismissal. I agree to comply with all orders, rules, regulations. policies, SOP’s, and by-laws of this squad. I further agree that I am physically and mentally qualified for membership as described in the “Qualifications for an Ambulance Attendant” (if applicable) provided with this application. I agree to submit to a physical examination by a licensed physician approved by the Squad. I agree to submit to a background check administered by the Police Department or agency designated by the Lambertville New Hope Ambulance & Rescue Squad. Please type your name below as a digital signature to this statement. *
Your answer
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