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Note: If you do not wish to submit the following information via the Internet, please print this form, and fax to (203) 881-5018 or mail it to:

Seymour Ambulance Association, Inc.
4 Wakeley St.
Seymour, CT 06483

Applicant Information

Full Name(required)
DOB(required)
SSN

Contact Information

Phone(required)
Email(valid email required)
Street Address
City / State / Zip

Employment Information

Employer Name
Street Address
City / State / Zip
Work Phone

Certifications / Licenses

Drivers License #
Drivers License State
CPR Expiration Date
First Aid Expiration
CT Certification
CT Cert. Number
CT Cert. Expiration

Membership Agreement

I certify that the information listed above is true to the bset of my knowledge, and that I will abide by the constitution and by-laws of the Seymour Ambulance Association, Inc. I further understand that all new applicants are subject to a criminal records check.