Seymour Ambulance Association Inc.

4 Wakeley St. Seymour, CT 06483

Volunteer Membership Application

Date Filled Out

Personal Information

Name:

Over 18 years old:
YesNo

Address:

City:

Zip:

Email:

Primary Phone:

Education

Name of School obtained from:

Date or anticipated date of graduation (month and year):

Location of school:

If attending college or school out of state please list any dates you will NOT be available:
If attending college or school out of state please list any dates you will NOT be available:

Criminal Records

Have you ever been convicted of a crime(s) or are currently under indictment?
YesNo

If yes please give a complete description of any al all incidents:
If yes please give a complete description of any al all incidents

Certifications

Level:
EMREMTAEMTParamedic

Certification Number:

Expiration:

CPR:
AHAARCNational Safety

Expiration:

Any additional licenses or certifications:
Any additional licenses or certifications:

Applicant signatures
I agree that all the information provided in the application above is true and accurate. I understand that if any information was falsified my application will be removed from consideration and I will not be able to reapply within a period of 90 days from the date below.

Applicant signature

Committee member signature

Date

I

of

City

State and Zip

Criminal Record Check Form

Freely authorize Seymour Ambulance Association Inc. to have a criminal, motor vehicle, and if necessary credit check done and authorize information to be released to them. I also agree to furnish a copy of my DD 214 form if requested.

Applicant Signature

Date

Arrest Record Information

Name

DOB

Address

City

State/Zip

Sex
MaleFemale

Race