Mohegan EMS Application Form
Personal Information
Name
*
First Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Date
SSN
*
Gender
*
Male
Female
Prefer not to say
Phone Number
*
-
Area Code
Phone Number
Home/Work Phone
*
-
Area Code
Phone Number
Email
*
example@example.com
Residence Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Year's at Address
*
Employment History
*
Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Education
Highest lever of Education
High School
Some College
Undergraduate
Graduate
Other
Are you currently enrolled in college or plan to attend college within the next 12 month?
I am not currently enrolled in school and I am not planning to attend within 12 months.
I am currently enrolled or planning to attend within 12 months - but will be able to continue to Volunteer. (e.g. attend school locally or online-only)
I am currently enrolled or planning to attend within 12 months - and will NOT be able to continue to Volunteer.
Other
Personal History
Do you have any physical limitations or other potential impediments (e.g criminal convictions, etc.) to your becoming a NYS certified EMR, EMT or Paramedic? (see NYS BEMS Policy Statement 00-10 and NYS BEMS Policy Statement 15-04)
*
Yes
No
NYS Bureau of EMS Policy 00-10: https://www.health.ny.gov/professionals/ems/pdf/00-10.pdfNYS Bureau of EMS Policy 15-04: https://www.health.ny.gov/professionals/ems/pdf/15-04.pdf
If yes
*
Have you ever had a Driver’s License suspended or revoked?
*
Yes
No
Have you ever been in an auto accident that resulted in death or injuries to parties involved?
*
Yes
No
Have you ever been convicted of a misdemeanor or felony?
*
Yes
No
Are there any charges pending against you in any court?
*
Yes
No
Do you have any physical or psychological limitations that might impair your ability to perform the necessary duties of this position?
*
Yes
No
Have you ever been a member of the U.S. Armed Forces?
*
Yes
No
If yes
Have you ever been a member of a Volunteer Ambulance Corps or Fire Department?
*
Yes, still a member elsewhere
Yes, but no longer a member
No
*required if "Yes"* Please list - organization name, start date, end date, reason for separation:
*
List other organizations you belong to
Additional Comments
Joining Us
Please select your availability for the given days and time
*
Monday - Days
Monday - Nights
Tuesday - Days
Tuesday - Nights
Wednesday - Days
Wednesday - Nights
Thursday - Days
Thursday - Nights
Friday - Days
Friday - Nights
Saturday - Days
Saturday - Nights
Sunday - Days
Sunday - Nights
What current certifications do you hold?
CPR
NYS EMT
NYS Paramedic
NYS CFR
Other
What positions would you like to perform at MVAC?
*
Driver (must be 21+ with clean Drivers License)
NYS EMT
Attendant (EMT Students Welcome
Youth Corps (Age 14-18)
Other
Prior Member Rejoining?
*
Yes
No
References
Please provide three educational or professional references. Personal references will not be accepted.
*
Affirmations
Notice
Notice: EMS agencies in NYS are required by law (Executive Law Section 837-s) to check applicants (who may be involved in the care or transportation of patients) personally identifying information against the Sex Offender Registry and make a determination of eligibility to become a member/employee pursuant to Correction Law Article 23-A.We may want to also add The agency (Mohegan VAC) may also conduct other background/reference checks including but not limited to the following areas: verification of identity, current and previous residences, employment history, education background, employment and personal references, criminal history records, driving records, and any other public records. By clicking "I agree" applicant agrees to allow Mohegan Volunteer Ambulance Corps to conduct such background checks.
By selecting "I agree" below, I do solemnly swear to affirm that the foregoing statements are completely true. If my application is accepted, I agree to abide by all rules and regulations of the Mohegan Volunteer Ambulance Corps. I agree that I must meet the minimum and on-going training standards before being qualified to ride and continue to ride the ambulance as a regular member of the crew
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: