Mamaroneck Emergency Medical Service

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MAMARONECK EMERGENCY MEDICAL SERVICE

220 North Barry Avenue Extension, Mamaroneck, NY 10543
TEL: 914.698.0688
FAX: 914.698.7315
www.mamaroneckems.org

APPLICATION FOR MEMBERSHIP

PERSONAL
       
Last Name
Date
First Name
MI
   
Street Address
Apt/Suite
City, State, Zip
Home Phone
Cell Phone
E-mail Address
       
DRIVER'S LICENSE INFORMATION
Are you licensed to drive? Please give us your Driver's License Number. Your driving record is not considered when applying for membership.
       
Drivers License # State Issued
Expiration Date    
       
CERTIFICATIONS
       
Certification 1 Expiration Date
Certification 2 Expiration Date
Certification 3 Expiration Date
Certification 4 Expiration Date
       
Additional Training or Qualifications
       
REFERENCES
Please list three people that know you well. Please list there name, phone number & email below..
       
NAME EMAIL ADDRESS WORK PHONE # HOME PHONE #
       
PARENTAL PERMISSION
If you are under 18 years of age, we require that a parent or legal guardian accept the below terms. Please have your Parent /Guardian fill out this section and they must agree by selecting the checkbox. An email will be sent to the listed Parent/Guardian email address automatically upon application submission
       
Parent First Name

I give permission to the above named applicant to apply for membership with Mamaroneck EMS. I also give permissionfor Mamaroneck EMS to inquire into a routine background character check for the above named applicant.

I Agree to above statement
Parent Last Name
Phone Number
Email Address
     
       
ADDITIONAL INFORMATION
       
Are you over 18? When is your availability?
How did you hear about MEMS Is there anyone at Mamaroneck EMS that you know?
Were there any other previous/present organizations you are involved in? (Fire,Ems, ETC)
What are you interested in becoming (Driver, EMT or Both?
       
ACKNOWLEDGEMENT
       

By signing below, I signify that I have applied for membership to the Mamaroneck Emergency Medical Service; that I have answered all questions truthfully and to the best of my knowledge; and that I fully understand that any intentional false statement may be grounds for dismissal from the department. Furthermore, I hereby grant to the Mamaroneck Emergency Medical Service permission to conduct a background check and contact my references, and any other persons or agencies who may have knowledge of me, my skills and my experience as may be deemed necessary. Your responses on this application do not in any way whatsoever disqualify you from membership.

       
Please type your signature here:  


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Mamaroneck EMS
220 North Barry Avenue Extension
Mamaroneck, New York 10543

Emergency Dial 911
Non-Emergency: 914-698-0688
E-mail: info@mamaroneckems.org
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