Member Application

Full Name

Date of Birth (YYYY-MM-DD)

Cell Phone Number

Home Address

Mailing Address (if different from above)

Are you a US citizen? (if no, please have work status info available ready upon interview)(required)

Yes No

Gender

Drivers License Number and State (if not applicable enter N/A)

Is your drivers license valid?(required)

Yes No

If no, how will you respond to calls while on duty?

Position applying for

What best describes your qualifications

Has your EMT ever been suspended or revoked? (Only applies to current or former EMTs)

Yes No

If yes, please explain

When do you think you will be able to respond to calls? (check all that apply)(required)

Weekdays (6:00am – 6:00pm) Weekdays (6:00pm – 6:00am) Weekends (6:00am – 6:00pm) Weekends (6:00pm – 6:00am)

Other

What day(s) are you available? (This is not a commitment to a schedule; your actual assignment will be determined based on a combination of your availability and our current staffing circumstances.)(required)

Do you have any experience in emergency services?(required)

Yes No

If yes, what organization(s)?

Are you still active on the above organization(s)?

Yes No

If no, please provide brief explanation

Have you ever been denied or expelled from any volunteer agency?(required)

Yes No

If yes, please explain

Are you currently, or have you ever been, certified in CPR?(required)

Yes No

Are you currently, or have you ever been, certified in First Aid?(required)

Yes No

Reference 1 (Include name, phone number, relation, and how long they have known you, and their mailing address)

Reference 2 (Include name, phone number, relation, and how long they have known you, and their mailing address)

Reference 3 (Include name, phone number, relation, and how long they have known you, and their mailing address)

Reference 4 (Include name, phone number, relation, and how long they have known you, and their mailing address)

The information that you provided will be independently verified. In addition to this information, acceptance will be determined based on an in-person interview with our membership committee, a background check, a medical evaluation, and successful completion of required training. Regardless of the position applied for, any applicant, who for legal reasons, is not eligible to sit for the NJ EMT exam (pursuant to N.J.A.C. 8:40A-6.2) will not be accepted for membership. Any application that has not been fully completed will not be considered for membership. In the acceptance of these terms, your signature on the following certification is required for your application to be considered.

Do you understand and agree with the above?(required)

Yes No

To the best of my knowledge, I have provided complete and accurate information on this application. I understand that my application for membership will be subject to a review of criminal history records, motor vehicle driver history abstracts, medical evaluation, and successful completion of required training. I understand that providing false information on this application will lead to rejection of my application, or termination of my membership. If I am accepted, I agree to abide by the Constitution and By-Laws of the Branchburg Rescue Squad and to maintain the confidentiality of all the Branchburg Rescue Squad business and patient information.

If you understand and agree with the above statement please type your full name in the area below, this will serve as an electronic signature.

Application

Thank you for your response. ✨

ACCEPTING NEW MEMBERS