MEMBERSHIP APPLICATION

NAME: _______________________________________ DOB: ___________________

RESIDENCE __________________________________________________

ADDRESS:

__________________________________________________

MAILING __________________________________________________

ADDRESS:

_________________________________________________

EMAIL: __________________________________________________

PHONE NO: (___________)_______________________________________

How long have you lived at your present address? ____ Years ___ Months

If less than 2 years, please list your prior addresses for the last two years:

Address From To

___________________________________________________________ _____ _______

___________________________________________________________ _____ _______

Do you intend to reside in the response area for the next few years? Yes____ No____

If no, please explain why not? (college, etc)

__________________________________________________________________________________

__________________________________________________________________________________

Are you at least sixteen years of age? Yes ____ No ____

Do you possess a valid driver’s license? Yes ____ No ____

Driver’s License Information: __________________________________________________________

Employment Information:

Name Address Position Dates of Employment

___________________________________________________________________________________

___________________________________________________________________________________

Do you have access to a vehicle to permit you to respond to the corps.? Yes____ No ____

Please check all of the positions for which you intend to become qualified and perform:

______ Active Riding ______ Associate ____Junior Corps. _____Limited Riding

List any relevant certifications, courses, trainings (please provide expiration dates, if any):

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

What is your highest grade/level of education completed? ________________________________

Have you previously belonged to another fire department or ambulance service? Yes ____ No ____

If so, provide name, address and years of service: ___________________________________________

Are you a citizen of the United States? Yes ____ No ____

If not, do you intend to become a citizen of the United States? Yes ____ No ____

If no, have you the legal right to remain permanently in the United States? Yes ____ No ____

Do you intend to remain permanently in the United States? Yes ____ No ____

Have you ever been convicted or plead to a criminal offense? Yes ____ No ____

Provide offense convicted of: ___________________________________

Date of conviction: ____________________________________________

How long ago was the conviction? ________________________________

Has a certificate of relief from disabilities been obtained? Yes____ No____

Have you ever been convicted of either of the following types of offenses?

An offense requiring registration as a sex offender Yes ____ No ____

Do you have any pending arrests? Yes ____ No ____

Have you reviewed the requirements for the position which you are interested? Yes ____ No ____

Can you perform the functions of at least one of the positions in which

you are interested, with or without reasonable accommodation*? Yes ____ No ____

(Please see the attached list of physical requirements)

* The Mount Kisco Volunteer Ambulance Corps. reserves the right to determine what is

reasonable.

Please provide three individuals who are not related who will share information regarding your potential service as a member of the ambulance corps:

NAME ADDRESS PHONE

____________________________________________________________________________________

____________________________________________________________________________________

APPLICANT

AGREEMENT FOR BACKGROUND CHECK

I, the above signed applicant, hereby consent to a criminal background check and to review of my

information as may be publicly posted on social media. I understand that this information will be utilized in the review of legal grounds for consideration of membership only but could result in denial of membership for legal reasons only.

____________________________________