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Galway Emergency Medical Services - Membership Application

* FIRST NAME

:

SOCIAL SEC #

:

-

 

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* LAST NAME

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* HOME PHONE #

:

-

 

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* ADDRESS

:

* DATE OF BIRTH

:

/

 

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:

   E-MAIL

 

 

* EMERGENCY CONTACT

:

 

* EMERGENCY PHONE #

:

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 EMPLOYER

:

WORK PHONE #

:

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WORK EXT.

:

 

DRIVERS LICENSE #

 

STATE OF D.L.

< EXPIRATION DATE

:

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* ARE YOU WILLING TO DRIVE AN ABULANCE?

:

SHIRT SIZE

:

 

* TOUR DESIRED

:

COAT SIZE

:

 

  OTHER (if selected)

:

* TYPE OF MEMBERSHIP

:

 

* LIST ALL TRAFFIC VIOLATIONS FOR PAST 3 YEARS

* LIST ALL TRAFFIC ACCIDENTS PAST 3 YEARS

* LIST ANY CIVIL OR FELONY CONVICTIONS

* LIST ANY PHYSICAL LIMITATIONS

 

Please enter any Certification Training Below

 

TRAINING

 

DATE OF EXPIRATION

 

LOCATION

 

ID #

C.P.R.

:

/

 

/

 

 

 

COMMUNITY FIRST AID

:

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/

 

 

 

E.M.T.

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1-ST RESPONDER

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OTHER MEDICAL TRAINING

:

LIST OF ORGANIZATIONS YOU BELONG TO

:

 

I ACKNOWLEDGE THAT I WILL BE ON PROBATION UP TO (6) MONTHS AND ALL THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE, AGREE TO ABIDE TO THE CONSTITUTION / BY-LAWS AND S.O.P.'S OF THE GALWAY EMERGENCY MEDICAL SERVICES, AND AUTHORIZE GALWAY EMERGENCY MEDICAL SERVICES TO OBTAIN INFROMATION REGUARDING MY BACKGROUND.

I Accept the above Terms and Conditions of this Application

 

Please print the completed form and mail it to:

Galway Emergency Medical Services

2175 Galway Road

Galway, NY.  12074

 


* Required Field

REVISED 01-20-05