Mamaroneck Emergency Medical Service

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Application for Membership

MAMARONECK EMERGENCY MEDICAL SERVICE

220 North Barry Avenue Extension, Mamaroneck, NY 10543
TEL: 914-698-0688
FAX: 914-698-7315
www.mamaroneckems.org

Required   Indicates Required Field
PERSONAL
Submitted Date/Time: 05/17/2021 1840
Name:
Last Name, First Name, Middle Initial
Required
Address:
Street Address, Apt/Suite, City, State, Zip
Required
Home Phone Number:
Cell Phone Number:
Email Address: Required
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:
FIRE / EMS CERTIFICATIONS
Certifications:
List certification and Expiration Date
Attach copy of certifications :
Add files...
REFERENCES
Please list three people that know you well. Please list there name, phone number & email below.
Reference #1:
Name, Email Address, Work Phone #, Home Phone #
Required
Reference #2:
Name, Email Address, Work Phone #, Home Phone #
Required
Reference #3:
Name, Email Address, Work Phone #, Home Phone #
Required
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.
Parent Name:
Parent Phone Number:
Parent Email Address:
Parent Permission: Yes
ADDITIONAL INFORMATION
Are you over 18? : Required
How did you hear about MEMS:
When is your availability?:
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?: Required Driver
EMT
Both
ACKNOWLEDGEMENT
Electronic Signature of applicant: Required

By signing above, 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.





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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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