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2020 PSVAC Membership Application
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* Indicates required question
Last Name, First Name, Middle Initial
*
Your answer
Cell Phones (Please enter the best number to reach you).
*
Your answer
Full Physical Address (Include City, State, Zip)
*
Your answer
CERTIFICATION LEVEL
*
Choose
EMT-B
EMT-P
CFR
Other
NYS EMS Certification Number
Your answer
NYS EMS Certification Expiration Date (MM/DD/YYYY)
MM
/
DD
/
YYYY
Do you have a Medical Clearance Form completed by your personal physician?
Yes
No
Do you have FEMA ICS-700, ICS-100, and ICS-200 certifications?
Yes ICS-700
Yes ICS-100
Yes ICS-200
Do you have a valid state driver's license?
Yes
No
How would you best describe your level of experience in EMS?
Choose
Professional
Experienced
Some Experience
Novice
EMT-P Student
No Experience
Please explain in a few sentences why you would like to join PSVAC as a member.
Your answer
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