2018 PSVAC Membership Application
Email address *
Last Name, First Name, Middle Initial *
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Email *
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Home & Cell Phones (Please enter the best number to reach you). *
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Full Physical Address (Include City, State, Zip) *
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NYS EMS Certification Number
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NYS EMS Certification Expiration Date (MM/DD/YYYY)
Do you have a Medical Clearance Form completed by your personal physician?
Do you have FEMA ICS-700, ICS-100, and ICS-200 certifications?
Do you have a valid state driver's license?
How would you best describe your level of experience in EMS?
Please explain in a few sentences why you would like to join PSVAC as a member.
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Additional application comments.
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