Bradley Gardens First Aid & Rescue Squad Inc.

P.O. Box 6522, Bridgewater, NJ 08807

 

APPLICATION FOR MEMBERSHIP

 

Squad Position Applying For: _________________________ Date: _______________

 

 

Full Legal Name: ____________________________________________________________

Maiden Name if Married Less than 2 Years: _____________________________________

Street Address: _____________________________________________________________

                        City: _______________________________ Zip: _______________________

Previous Address (only if you have lived at the above address for less than 2 years):

                        _______________________________________________________________

                        City: _______________________________ Zip: _______________________

Home Phone #: ________________________ Cell Phone #: _________________________

Email Address: _____________________________________________________________

Date of Birth: __________________ Age: ____ Sex: ____ SS#: _______-_____-_________

Driver’s License #: _______________________________ Exp. Date: _________________

* Please attach a copy of your driver’s license or state certified identification to this application.

Marital Status: _______________ Spouse’s Name (if applicable): _____________________

List Any Physical Handicaps: _________________________________________________

Have you ever been convicted of a crime? _______________________________________

            If yes, please explain: __________________________________________________

                                                 ___________________________________________________

Do you have offenses on your driving record? ____________________________________

            If yes, please explain: __________________________________________________

                                                 ___________________________________________________

Will you agree to a police background check and fingerprinting?  Yes ____ No ____

 

Will you agree to a physical by a licensed medical doctor if asked?  Yes ____ No ____

 

 

Name of Employer: __________________________________________________________

Employer’s Address: _________________________________________________________

                        City: _______________________________ Zip: _______________________

Phone #: ___________________________ Supervisor: _____________________________

Occupation: ________________________________________________________________

Years Worked: ______________ Normal Work Hours: ____________________________

 

 

Name of Organization: _______________________________________________________

Address of Organization: _____________________________________________________

                        City: _______________________________ Zip: _______________________

Years of Membership: ______ Current Status With This Organization: ______________

Reason for Leaving: _________________________________________________________

*Please attach another page if you need to elaborate on your EMS experience.

 

 

Highest Level of Formal Education: ____________________________________________

Please list all education related to EMS with expiration dates of cards where applicable:

 

 

Name: _____________________________________________________________________

Address: ___________________________________________________________________

Phone #: ________________________ Type of Reference: __________________________

 

Name: _____________________________________________________________________

Address: ___________________________________________________________________

Phone #: ________________________ Type of Reference: __________________________

 

Name: _____________________________________________________________________

Address: ___________________________________________________________________

Phone #: ________________________ Type of Reference: __________________________

 

Name: _____________________________________________________________________

Address: ___________________________________________________________________

Phone #: ________________________ Type of Reference: __________________________

 

Name: _____________________________________________________________________

Address: ___________________________________________________________________

Phone #: ________________________ Type of Reference: __________________________

 

 

I certify that the answers given herein are true and complete to the best of my knowledge.  In the event of membership, I understand that false or misleading information given in my application or interview may result in discharge from the organization.  I also understand that I am required to abide by rules and regulation of the organization.

 

Signature: ________________________________________ Date: ____________________

Parent/Guardian’s Name (if applicable): ________________________________________

Parent/Guardian’s Signature: ________________________________ Date: ___________

Do Not Write Below This Line – Office Use Only

 

Date Accepted as a Probationary Member: ______________________________________

Officer’s Signature: ______________________________________________ ID #: ______

 

Date Accepted as a Regular Member: ___________________________________________

Officer’s Signature: ______________________________________________ ID #: ______