Brentwood Legion Ambulance
Membership Application
Membership Selection
Select Interested In:
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Riding Member
Committee Member
Associate Member (Requires Membership in a Fire or Ambulance Department
How Did You Hear About Us?:
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Website
Member of The Department
Friend
Open House
Social Media
Other
Are You Willing To Enroll in a New York State EMT Class?:
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Yes
No
Maybe
Already Certified
Are You Willing To Complete a Driver's Training Course? (Min. Age To Take Course is 20 Years Old):
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Yes
No
Maybe
N/A - Under 20
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Personal Information
Name:
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First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number:
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Format: (000) 000-0000.
E-mail:
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example@example.com
Social Security Number:
*
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Employment & Volunteer History
Any False Statements Will Disqualify Your Application
Were You a Member of a Volunteer or Paid Fire Department or Volunteer Ambulance Company in Which You Had to Resign, Were Withdrawn or Was Terminated?:
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Yes
No
Not Applicable
Are You Still a Member Of a Volunteer Ambulance Company or Fire Department?:
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Yes
No
Not Applicable
What Department Were You a Member Of? Enter Approximate Dates (Months/Year):
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List 3 Previous Places of Employment Approximate The Start and End Dates (Month/Year) If Not Applicable, Write N/A:
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List 3 Character References
Name #1:
First Name
Last Name
Phone Number #1:
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Please enter a valid phone number.
Format: (000) 000-0000.
Email #1:
example@example.com
Name #2:
First Name
Last Name
Phone Number #2:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email #2:
example@example.com
Name #3:
First Name
Last Name
Phone Number #2:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email #2:
example@example.com
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Background
Any False Statements Will Disqualify Your Application
Do You Have Any Criminal Convictions? Or Have You Ever Been Convicted of a Crime?:
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Yes
No
Please Disclose Any Convictions or Crimes You May Have Been Convicted Of:
*
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Certification & Licenses
Any False Statements Will Disqualify Your Application
Do You Hold a Valid New York State Drivers License?:
*
Yes
No
Not Applicable
Upload Your New York State Drivers License (FRONT)
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Upload Your New York State Drivers License (BACK):
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Have You Ever Had Any Traffic Violations or Accidents on Your Driving Record?:
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Yes
No
Not Applicable
What Are The Violations and Approximate Dates in Which They Occurred:?
Upload Your New York State EMT, EMT-CC, EMT-A or Paramedic Certification:
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Background Checks & Disclosures
I Acknowledge That By Signing My Name Below Any and All Statements Made in This Application is Considered Factual. I Acknowledge That Any False Statements Made is and Will Be An Automatic Disqualification For Consideration of Membership For This and Any Future Attempts at Applying For Membership at Brentwood Legion Ambulance.:
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I Acknowledge That By Signing My Name Below I Approve Brentwood Legion Ambulance and Its Recruitment Personnel To Conduct a Background Check Which Will Include Reaching Out to Character Witness, Past or Current Employers, and Past or Current Ambulance and Fire Departments:
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I Acknowledge That By Signing My Name Below I Approve Brentwood Legion Ambulance To Use a Third-Party Background Company and Suffolk County Police Department To Conduct a Basic Criminal Background Check, Conduct a Sex Offender Registry Check, and An Arson Background Check.
*
Enter the Message As It's Shown:
*
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