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    Seymour Ambulance Association Inc.

    4 Wakeley St. Seymour, CT 06483

    Volunteer Membership Application


    Personal Information









    Military Service (If applicable)


    ArmyNavyMarinesAir ForceCoast Guard




    Work Experience (If applicable)











    Education


    Attending High SchoolH.S. DiplomaAssociate DegreeBachelor Degree





    Emergency Service Experience (If applicable)














    Driving Record (If applicable)




    YesNo



    Criminal Records


    YesNo



    Certifications


    EMREMTAEMTParamedicEMS Student



    AHAARCNational Safety


    Driving (If applicable): CEVOEVOC



    Availability (If applicable)
    From








    To:








    Our shifts are in 6hr blocks and run 6a-noon, noon-6p, 6p-midnight, and midnight-6a.


    Applicant Signature

    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.








    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.




    Arrest Record Information