Please provide all information requested or you can download the form, fill out and send back to us. YVAC Headquarters, Yorktown Volunteer Ambulance Corps, PO Box 104, Yorktown Heights, NY 10598, Attn: Membership Committee Chairperson

Name* (First, M.I.,Last):
Street Address*:
City*: State*: Zip*:
Home Phone*: Alternate Phone*:
Are you 18 yrs or older?
References: Please give only references which you have known for at least 5 years. (no Clergy, family members or Corps members)
1st Reference
Name*: Address*: Phone*:
2nd Reference
Name*: Address*: Phone*:
Name of Friend or Relative in the Corps (if any):
Have you any objections to this organization making inquiries regarding your character and qualification from:
A. Former employer?:
B. Present employer?:
If answer is "Yes" to either (a) or (b) , please explain:
Present Employment
Firm Name*: Business Type*:
Former Employment
Firm Name*: Business Type*:
Education
School Name: Year*: Deg.*:
List your level of experiences including certificates and licensing pertaining to the medical profession (CFR, EMT-D, EMT-I OR EMT-P, ETC.) :
Certified in CPR?
Expiration date:
Except for minor traffic violations, were you ever been convicted of any violation of the law?
Current or former member of an Ambulance Corps or Rescue Squad?
Agency Name:
Do you have any physical disabilities or limitations?
Which shift would you prefer to ride? Select one:
What day or days would be most convenient for you?
Declaration:I declare, subject to the penalties of perjury, that the above statements made in this application have been examined by me and to the best of my knowledge are true and accurate.
Name*:
Date*:
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