Randolph Rescue Squad Application
|
| Name
*
|
|
| Prefix
|
|
| First
*
|
|
| Last
*
|
|
| Suffix
|
|
| Date of Birth
*
|
|
| Address
*
|
|
| Street Address
*
|
|
| Address Line 2
|
|
| City
*
|
|
| State / Province / Region
*
|
|
| Postal / Zip Code
*
|
|
| Country
*
|
|
| Email
*
|
|
| Phone Number
*
|
|
| 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:
|
|
| Reference 2 (not related):
*
|
|
|
Image Verification
|
|
|
|
|
|
EMF Online Survey
EMF Online Survey