Randolph Rescue Squad Application
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Name
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Prefix
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First
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Last
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Suffix
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Date of Birth
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Address
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Street Address
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Address Line 2
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City
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State / Province / Region
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Postal / Zip Code
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Country
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Email
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Phone Number
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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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Street Address
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Address Line 2
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City
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State / Province / Region
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Postal / Zip Code
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Country
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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 charged 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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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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Image Verification
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