Town of Liberty Volunteer Ambulance Corps

Town of Liberty Volunteer Ambulance Corps Membership Application

        Name

        Address        City        State        Zip Code

            Home Phone

            Cell Phone

            Email

        Are you at least 18?
                Yes        No
        If not, can you provide valid working papers?
                Yes        No

        Have you ever been a member of an ambulance corps?    Yes        No
            If yes, which one?        Contact Person

        Certifications
            Please check all that apply.
                None        CPR        CFR        EMT        EMT-I or EMT-CC        Paramedic        Other
                    EMT Card #

        Have you ever been convicted of a crime?    Yes        No
            If yes, please explain


        Please provide three references. One must be a work reference, no family members please.
            1)        Phone
            2)        Phone
            3)        Phone

        When are you available? Please check all that apply.
                Days        Evenings        Nights        Weekends

        Driver's License #        Expires

        I hereby give the Town of Liberty Volunteer Ambulance Corps permission to check my background and driving record. I also certify that all information contained in this application is truthful and accurate.
            Enter your initials