MEMBERSHIP APPLICATION

Name: Your Full Name

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Email: name@email.com

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Driver's License Number: Enter DL#

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SUBMIT

Phone: xxx-xxx-xxxx

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Address: Enter Address

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City: Enter City

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State: State

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Zip code: Enter Zip

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Age: Age

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Date of Birth: mm/dd/yyyy

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SSN: Social Security Number

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Class: Class

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Expiration Date: mm/dd/yyy

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State of Issue: State

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Have you ever been arrested and/or convicted or received probation before judgment for any misdemeanor, felony or motor vehicle violation, other than parking tickets? Yes or No

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Do you currently have any active motor vehicle “points” on your driving record?  If yes, how many? Yes or No. If yes, how many?

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Do you have any physical limitations that preclude you from performing any work for which you are being considered? Yes or No. If yes, please describe your physical limitations.

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Are you willing to take a physical examination? Yes or No

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Are you willing to undergo an alcohol and/or drug test? Yes or No

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May we conduct an official background check on you? Yes or No

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Emergency Contact Name: Emergency Contact's Full Name

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Relationship to You: Emergency Contact's Relationship to You

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Emergency Contact Address: Emergency Contact's Full Mailing Address

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Home Phone: xxx-xxx-xxxx

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Mobile Phone: xxx-xxx-xxxx

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Have you ever applied for membership previously with Emmitsburg Volunteer Ambulance Company?  If yes, were you accepted? And, if you served as a member, when and why did you leave? Yes or No.  If yes, please provide additional information.

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Have you been, or are now, a member of another ambulance service or fire department? If yes, please list dates of membership and reason for leaving with the name and address of the chief officer. Yes or No, If yes, please provide name, dates, reason for leaving and contact information for the chief officer.

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Have you ever been suspended, rejected or denied membership from any other ambulance service or fire department? If yes, please explain. Yes or No. If yes, please explain.

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Do you or have you ever held a certification for any special training relating to emergency care, fire or rescue?  If yes, please list them here and email (estackhouse@emmitsburgems.net) or mail copies of certification cards or training certificates. Yes or No. If yes, please list your certifications or trainings here.

Required

The Emmitsburg Volunteer Ambulance Company Inc. is an equal opportunity organization and does not discriminate on the basis of sex, race, religion national origin, age, sexual orientation, physical or mental disability. In keeping with the Americans with Disabilities Act and the Equal Opportunity Employment Act, we will make reasonable accommodations to facilitate membership for people with disabilities. It should be understood that some disabilities might preclude a person from Operational Membership, due to the physical requirements of the work. If you require any accommodations please indicate them in the space provided: Please indicate any special accommodations here.

Required

Parent's Full Name (if Applicant is a Minor): Parent's Full Name (if Minor Applicant)

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Applicant's Full Name: Applicant' Full Name

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RELEASE OF INFORMATION

 

I hereby submit this application for membership to the Emmitsburg Volunteer Ambulance Company Inc. I hereby certify and affirm that all information contained herein is true and accurate to the best of my knowledge.

 

I hereby grant permission to the Emmitsburg Volunteer Ambulance Company Inc. and/or its duly appointed representatives to conduct a thorough check of my background. I hereby grant permission for the release of any information pertaining to the above investigation to the proper representative of the Emmitsburg Volunteer Ambulance Company Inc. and release all parties from any liability for disclosure of person information.

 

I understand that any false or misleading information submitted on the application or omission of information requested by this application for the purpose of misleading or falsely representing myself to the organization is grounds for rejection of this application. If any of the information on this application is found to be false once I am accepted for membership, this will be cause for immediate termination. I also understand that I will be required to complete a 6 month probationary period and will be required to compete the training required for my level of membership.

 

I hereby agree to abide by the By-laws and Standard Operating Procedures of the Emmitsburg Volunteer Company Inc. I understand that my membership with the Emmitsburg Volunteer Ambulance Company Inc. is an employment at will relationship and may be terminated by me or the company at any time, without prior notice.

 

By typing my full name below and submitting this form, I provide my digital signature and agreement to this release.

Copies of certifications and training may be emailed here or mailed by post to the following address:

 

Emmitsburg Volunteer Ambulance Company

17701 Creamery Road

Emmitsburg, MD 21727