West Orange First Aid Squad Membership Application

Personal Details

Last Name: *

First Name: *

Middle: *

Date of birth: * e.g. 06/22/1979

Home Phone #: *

Cellular #:

Email Address: *

Address

Street Address: *

Line 2:

City: *

State: *

Zip Code: *

Application Details

Please list any pre-hospital care certifications you possess (cpr, emt-b, cevo)

Have you ever been convicted of a crime?

Yes No

If yes, please explain.

Name of High School and City/State Attended.

High School: *

City: *

State: *

Name of College Attended:

Employment Information

Present or last position.

Employer:

Job Title:

Supervisor Name:

Supervisor Tel#:

Previous position.

Employer:

Job Title:

Supervisor Name:

Supervisor Tel#:

Previous position.

Employer:

Job Title:

Supervisor Name:

Supervisor Tel#:

References

First Reference:

Name:

Telephone #:

Second Reference:

Name:

Telephone #:

Third Reference:

Name:

Telephone #:

Available times to volunteer

We generally run 2 shifts each weekday. 7 am to 7pm and 7pm to 7 am. The first is the "day shift" and the second is the "night shift" These run 5 days a week-we have special rotating coverage over the weekends. Please check below the shift or shifts that your available time falls under.

Mondays:

Tuesdays:

Wednesday:

Thursdays:

Fridays:

I Certify that the statements contained herein are true to the best of my knowledge. I understand that any Incomplete, inaccurate, misleading, false or incorrect information may result in rejection of my application, Disqualification from consideration, may render an appointment void and/or can be cause for my dismissal upon discovery. Check "Yes I Agree".

Yes I Agree