42-18 Marathon Parkway
Little Neck, NY 11363
(718) 423-2333
APPLICATION FOR MEMBERSHIP
PLEASE PRINT CLEARLY OR TYPE ALL INFORMATION
Last Name____________________________ First Name______________________ M.I.:______
Address________________________________________________________ Apt #:__________
City:_____________________________ State:_________________ Zip Code:_______________
Home Telephone:_________________________ Work Telephone:________________________
Cell Telephone:___________________________ Pager Telephone: _______________________
Internet E-Mail Address:__________________________________________________________
Gender: Male______ Female:______ Date of Birth:___________ Social Sec. #:______________
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EMPLOYMENT INFORMATION: Not Currently Employed:________
Name of Last/Current Employer:___________________________________________________
Address:_______________________________________________________________________
Supervisor:____________________________ Supv. Phone: _____________________________
Position:_______________________________________ Length of time at Employer:________
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EDUCATION INFORMATION: High School:____ College: ____ Graduate: ___
Name of School Now/Last Attended:________________________________________________
Highest Grade Completed:_____________________________ Year Graduated: _____________
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CURRENT / PRIOR EMS ORGANIZATION MEMBERSHIP INFORMATION
Name of Organization:___________________________________________________________
Start Date of Membership:_______________ Reason for Leaving:_________________________
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Applicant Name:___________________________________ Date:_____________
PLEASE ANSWER ALL QUESTIONS BELOW: (explain any “YES” answers) YES NO
1) Why do you wish to join our volunteer ambulance corps?
2) Are you involved in any other groups / organizations?
3) Are you fluent in any languages besides English?
4) Are you REQUIRED to perform community service?
5) Have you ever been convicted of a Misdemeanor or Felony Crime?
6) Has this or any other ambulance organization ever denied you membership?
7) Have you ever been disciplined by any agency or organization while serving as a health care provider?
8) Has your driver’s license ever been suspended or revoked?
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MEDICAL TRAINING INFORMATION: No Medical Training:_____________
List ALL current Licenses and certifications and attach a copy of all:
CPR_____ CFR_____ EMT-D_____ EMT-I_____ EMT-A_____ EMT-P_____ RN_____ MD_______
1) Training Organization Name:________________________________________________
Certification / License Number:__________________________ Exp Date:__________________
2) Training Organization Name:________________________________________________
Certification Number:__________________________________ Exp Date:__________________
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Applicant Name:____________________________________ Date:____________
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PLEASE LIST TWO NON-FAMILY PERSONAL REFERENCES
Name:________________________________________________________________________
Address:_______________________________________________________________________
Telephone Number:_____________________________________________________________
Relationship to Applicant:_________________________________________________________
Length of time Known by Reference:________________________________________________
Name:________________________________________________________________________
Address:_______________________________________________________________________
Telephone Number:_____________________________________________________________
Relationship to Applicant:_________________________________________________________
Length of time Known by Reference:________________________________________________
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I affirm that the above application contains no misstatements or omissions and is completely true and correct. If my application is accepted, I agree to abide by all the rules and regulations of the Little Neck – Douglaston Community Ambulance Corps (“LNDCAC”) at all times. I further authorize LNDCAC to verify the information I have provided in this application. False statements made here on this application may result in my suspension and/or revocation of membership.
By accepting membership to LNDCAC, I agree to serve during designated hours and make myself available at such times. In addition, I am expected to offer my time whenever possible when called upon to relieve a fellow member. I may be called upon in an emergency even though it may not be my duty time.
I understand that my membership application will be reviewed by the Operations Committee who will determine if approved for membership, and I understand that my application is conditional on the following requirements: (a) If applying for ambulance duties, I have been examined by a medical physician who has determined me to be fit for those duties and (b) having completed a 6-month probationary period. During that time, corps officers and the training and operations committee will have monitored and evaluated my performance.
I herby accept and agree to all the terms of this application.
Name:________________________________Signature:__________________________ Date:________
Please complete application and the mail to:
Little Neck - Douglaston Community Ambulance Corps
42-18 Marathon Parkway
Little Neck, NY 11363
Or e-mail us at president@lndamb.org and we will mail you an application
THANK YOU FOR YOUR INTEREST IN JOINING OUR RANKS and
MAKING A DIFFERENCE IN OUR COMMUNITY!
