Randolph Rescue Squad
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| Name
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| Date of Birth
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| Address
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| Occupation:
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| Employer:
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| Years employed:
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| Employer Address:
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| Email
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| Phone Number
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| Driver's License #, State, Exp.
*
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| Are you a citizen of the USA
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| Yes No
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| Are you a legal alien?
| Yes No
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| Have you ever been convicted in a criminal, disorderly person, or domestic matter?
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| Yes No
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| If yes, please explain.
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| Have you ever been convicted of a motor vehicle violation in the state of NJ or any other state?
| Yes No
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| If yes, please explain.
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| Is your driving privilege now or has it ever been suspended or revoked in NJ or any other state?
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| Yes No
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| If yes, please explain.
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| Do you own or have access to a motor vehicle
| Yes No
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| Have you ever taken a defensive driving course?
| Yes No
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| Would you object to taking a defensive driving course?
| Yes No
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| Is there any medical or physical reason why you would be unable to safely drive an ambulance, assist in lifting a heavy patient, or perform the duties of a member of the squad?
| Yes No
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| If yes, please explain.
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| Have you ever belonged to a fire department or EMS unit?
| Yes No
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| If yes, please list the unit, membership dates, person to contact and why you left.
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Education and Professional training
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| High School (highest level completed)
| 1 2 3 4
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College
(highest level completed)
| 1 2 3 4
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| EMS Training (current)
| Professional CPR First Responder EMT A/B Emt D Paramedic Nurse Physician Other (enter below)
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| Other
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| Are you available to attend EMT classes?
| Yes No
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| What languages do you speak?
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| Please check all days of the week that you would be available for a 12 hour shift. Squad requires one weeknight shift per week and 2 weekend shifts per month.
| Monday 6PM - 6AM Tuesday 6PM - 6AM Wednesday 6PM - 6AM Thursday 6PM - 6AM Friday 6PM - 6AM Saturday 6AM - 6PM Saturday 6PM - 6AM Sunday 6am - 6PM Sunday 6PM - 6AM
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| When are you available for an interview?
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| Why do you want to join the Randolph Rescue Squad?
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| Reference 1 (not related):
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| Reference 1 Phone:
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| Reference 2 (not related):
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| Reference 2 Phone:
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| I hereby certify that the information stated on this application is true to the best of my knowledge. I understand that any falsely stated information may result in suspension and/or dismissal from the Randolph Rescue Squad at any time. By signing this application, I give the Randolph Rescue Squad the authority to investigate any personal background information, criminal history, and my driver's license record as requested by the Squad.
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| Yes
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For Squad Use only:
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| Applicant Signature:
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| Date:
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| Date Interviewed:
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| Members Present:
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| Date to Board:
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| Date Sworn in:
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| Comments:
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Image Verification
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EMF Online Form