APPLICATION FOR MEMBERSHIP

Sea Bright Emergency Medical Services

1099 Ocean Ave Sea Bright NJ, 07740

seabrightems@outlook.com

Name*

FIRST NAMELAST NAMESUFFIX

Annual MemberSeasonal Member (May 1- September 31)Cadet (Ages 16-18)

Date of Birth *

Address*

CELL*

DRIVERS LICENSE NUMBER *

EMAIL ADDRESS*

example@example.com

EMERGENCY SERVICE TRAINING: NAME OF COURSE DATE COMPLETED

NJDOH EMT #

National EMT #

PRIOR MEMBERSHIP TO ANY EMERGENCY SERVICES ORGANIZATION: ORGANIZATION NAME DATE OF MEMBERSHIP

HAVE YOU EVER BEEN SUSPENDED OR REMOVED FROM A PRIOR EMS ORGANIZATION?

HAVE YOU EVER BEEN CONVICTED OF A CRIME OR OFFENSE?

IF YES PLEASE DESCRIBE BELOW: DATE-JURISDICTION, CRIME, OFFENSE

ARE YOU CURRENTLY EMPLOYED IN SEA BRIGHT?

I certify that the statements made within this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I am aware that any misrepresentation of information supplied by me will result in my disqualification from the selection process. Furthermore, I authorize the Sea Bright Police Department to verify all information contained herein and to review my employment, education and criminal history, disciplinary records, and any other records and information from any source as noted in the duly executed Authority and Release form. I have read this Certification and I understand and agree to the conditions imposed herein.

DATE*

Date

APPLICANTS NAME PRINT*

APPLICANTS SIGNATURE*