Randolph Rescue Squad Application

Name *
Prefix
First *
Last *
Suffix
Date of Birth *

MM
/
DD
/
YYYY
Address *
Street Address *
Address Line 2
City *
State / Province / Region *
Postal / Zip Code *
Country *
Email *
Phone Number *

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Occupation:
Employer:
Years employed:
Employer Address:
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Driver's License #, State, Exp. *
Are you a citizen of the USA *
 Yes 
 No 
Are you a legal alien?
 Yes 
 No 
Have you ever been charged in a criminal, disorderly person, or domestic matter? *
 Yes 
 No 
If yes, please explain.
Have you ever been convicted of a motor vehicle violation in the state of NJ or any other state?
 Yes 
 No 
If yes, please explain.
Is your driving privilege now or has it ever been suspended or revoked in NJ or any other state? *
 Yes 
 No 
If yes, please explain.
Do you own or have access to a motor vehicle
 Yes 
 No 
Have you ever taken a defensive driving course?
 Yes 
 No 
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 
If yes, please explain.
Have you ever belonged to a fire department or EMS unit?
 Yes 
 No 
If yes, please list the unit, membership dates, person to contact and why you left.

Education and Professional training

High School (highest level completed)
 1 
 2 
 3 
 4 
College
(highest level completed)
 1 
 2 
 3 
 4 
EMS Training (current)
 Professional CPR 
 First Responder 
 EMT A/B 
 Emt D 
 Paramedic 
 Nurse 
 Physician 
 Other (enter below) 
Other
Are you available to attend EMT classes?
 Yes 
 No 
What languages do you speak?

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 
When are you available for an interview?
Why do you want to join the Randolph Rescue Squad?
Reference 1 (not related): *
Reference 1 Phone:

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Reference 2 (not related): *
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