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Demographics

Full Name

Email Address

Street Address

City

State/Province

Postal Code

Phone Number

Position

What position are you applying for?

Active Member

Do you have any EMS or Fire Service experience?

Yes No

If yes, what EMS or Fire Company are you affiliated with?

What is your occupation?

Referral

How were you referred to Tri-Town?

Facebook Other Social Media Tri-Town Member Other

If you were referred by a Tri-Town member, who referred you?

Certifications

What certifications do you currently hold?

CPR/BLS

ACLS

PALS

ITLS/PHTLS

CCEMT-P/CC-P/FP-C

NREMT/NRAEMT/NRP

NYS CIC/CLI

EMS Certification

Do you currently hold a NYS EMS Certification?

Yes No

If yes, what level of care are you currently certified at?

EMT-Basic AEMT AEMT-CC AEMT-P

When does your certification expire?

What is your NYS EMT Number?

Driver's License

Do you have a currently valid Driver's License?

Yes No

If yes, what state or province issued your Driver's License?

What is your Driver's License Number?

Are you over the age of eighteen (18)?

Yes No

If no, please provide your Date of Birth.

Application Disclaimer

I hereby represent and warrant that the answers included in my application are true and correct and are given for the purpose of securing membership to Tri-Town Ambulance Service, Inc. If elected to membership, I hereby agree to abide by the constitution, By-Laws, SOGs and regulations of Tri-Town Ambulance Service, Inc. Failure to be truthful in this application form will be grounds for immediate dismissal. This application must be approved by the Board of Directors following receipt of the application.

Tri-Town prohibits discrimination on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, and sexual orientation.

I authorize Tri-Town Ambulance Service Inc to obtain an investigative criminal record search, motor vehicles search and registered sex offender search before membership is granted and at anytime while I am a member. I authorize the release of information from previous employers and references. This investigation is strictly confidential. This report is compiled from sources that are believed to be reliable, but the accuracy of which cannot be guaranteed.

I agree to hold Tri-Town Ambulance Service, Inc free and harmless of any liability for any damages arising from any improper use of this information. I certify that my answers are true and complete to the best of my knowledge. If this application leads to membership, I understand that false or misleading information in my application or interview may result in my dismissal from the company.

I understand and agree to complete a minimum of twelve (12) scheduled duty hours per month on Unit 1 or "ALS on Duty" as defined by the SOGs. Failure to meet or exceed the twelve hours of duty per month may result in my membership termination. I also understand that I will not be signed off for any recertification and/or be permitted to participate in our CME program if I am not a member in good standing as defined by the SOGs and By-Laws of Tri-Town Ambulance Service, Inc.

I hereby agree to the Application Disclaimer as outlined above.

Yes No