2020 PSVAC Membership Application
Last Name, First Name, Middle Initial
Cell Phones (Please enter the best number to reach you).
Full Physical Address (Include City, State, Zip)
NYS EMS Certification Number
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.
Send me a copy of my responses.
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This form was created inside of Park Slope Volunteer Ambulance Corps.