Membership Application
First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
Telephone Number
Your answer
Email Address
Your answer
Date of Birth *
MM
/
DD
/
YYYY
References *
Please list two. Include Name, Phone Number and Email Address
Your answer
General Information
Have you applied to join another Fire/Rescue/Ambulance Organization? *
If yes, please name the organization
Your answer
Have you been refused membership from any EMS organization?
If yes, please name the organization
Your answer
What was the reason for refusal?
If unknown, please list unknown.
Your answer
Have you ever been a member of an ambulance corps?
If yes, name officer to contact for a reference.
Your answer
Have you applied to USRVAC before?
Have you driven an emergency vehicle before?
If yes, please indicate what and when
Your answer
Have you ever been convicted of a crime?
If yes, please explain.
Your answer
Driving Record
Moving Violations
Please list any moving violations for the last three years including type, place and date.
Your answer
Have your driving privileges ever been suspended or denied?
Agreement
It is agreed and understood that misrepresentation of information given shall be an act of dishonesty.

It is agreed and understood that the organization may investigate the applicant's background to ascertain any and all information of concern to the applicant's records. The applicant releases the organization and persons named herein, from all liability for any damages on account of his/her furnishing such information.

The applicant agrees to furnish additional information and complete examination as may be required to complete his/her file.

It is agreed and understood that this application for acceptance in no way obligates the organization to accept the application.

It is agreed and understood that if accepted, the applicant will be on a six month probation period.

It is agreed and understood that all certifications required by the organization will be up to date when acting in an active capacity. The captain will be notified when any of these certifications expire.

I give consent to the Upper Saddle River Volunteer Ambulance Corps representative to check any or all of the following: Driver's License Records, Municipal Arrest Recording System, NCIC/SCIC records.

I agree to be responsible and take proper care of the equipment that will be lent to me by the Corps. I agree to return all equipment when requested or when leaving the Corps. I will be liable to the Corps for the replacement cost of any equipment damaged or not returned. (Key, Blue Light, Pager, Uniform Jump Suite and/or Dress Shirt, Summer Jacket, Winter Jacket, Etc.)

I agree to maintain confidentiality about calls.

This certifies that this application was completed by me. That all entries are true and complete to the best of my knowledge. I understand that all my medical information will be kept confidential. I certify that I have no physical or mental disabilities that would impede my performance or endanger the patient or another Corps. member.

Acceptance of this application will be subject to membership committee review. Probation period will not start until all required documents have been submitted. At successful completion of probationary period candidate will be eligible for active membership.

I certify that I intend my electronic signature to be the legally binding equivalent of my traditional handwritten signature.

Agreement Signature *
Please type your full name.
Your answer
Agreement Signature (Parent or Guardian of Minor)
Your answer
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This form was created inside of USR Volunteer Ambulance Corps.