Fill the form below or download the PDF file and Upload it back here. Seymour Ambulance Association Inc. 4 Wakeley St. Seymour, CT 06483 Volunteer Membership Application Date Filled Out Personal Information Name: Over 18 years old: YesNo Address: City: Zip: Email: Primary Phone: Military Service Branch: ArmyNavyMarinesAir ForceCoast Guard Date Entered: Date Discharged: Current or Last Rank: Work Experience Most Recent Employer: Date(s) of Employment: Position/ Title: Address of Employer Brief Description of Duties: Brief Description of Duties Previous Employer: Date(s) of employment: Position/ Title Address of Employer: Brief Description of Duties: Brief Description of Duties Education Highest Level of Education: Attending High School H.S. Diploma Associate Degree Bachelor Degree GED Name of School obtained from: Date or anticipated date of graduation (month and year): Location of school: If attending college or school out of state please list any dates you will NOT be available: If attending college or school out of state please list any dates you will NOT be available: Emergency Service Experience Name of Organization: Date(s) of Membership: Supervisor: Brief Description of Organization Brief Description of Organization Name of Organization: Contact Phone: ext. Date(s) of Membership: Supervisor: Contact Phone: ext. Brief Description of Organization: Driving Record CT State Driver’s License Number: Date of Expiration: Has your license ever been suspended or revoked? YesNo If yes please explain: If yes please explain Criminal Records Have you ever been convicted of a crime(s) or are currently under indictment? YesNo If yes please give a complete description of any al all incidents: If yes please give a complete description of any al all incidents Certifications Level: EMREMTAEMTParamedic Certification Number: Expiration: CPR: AHAARCNational Safety Expiration: Driving: CEVOEVOC Any additional licenses or certifications: Any additional licenses or certifications: Availability From Sunday Monday Tuesday Wednesday Thursday Friday Saturday To: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Our shifts are in 6hr blocks and run 6a-noon, noon-6p, 6p-midnight, and midnight-6a. I agree that all the information provided in the application above is true and accurate. I understand that if any information was falsified my application will be removed from consideration and I will not be able to reapply within a period of 90 days from the date below. Applicant signature Committee member signature Date I of City State and Zip Criminal Record Check Form Freely authorize Seymour Ambulance Association Inc. to have a criminal, motor vehicle, and if necessary credit check done and authorize information to be released to them. I also agree to furnish a copy of my DD 214 form if requested. Applicant Signature Date Arrest Record Information Name DOB Address City State/Zip Sex MaleFemale Race
