Adult Corps Application

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth (mm/dd/yyyy) *

Email *

Home Phone *

Cell Phone *

Employer or School Address *

Line 1

Line 2

City

State

Zip Code

Country

Work Phone *

How Long There *

Name of Person to Notify in Case of Emergency *

Relationship *

Please give only references that you have known for at least 5 years.
(No family members, or Peekskill Ambulance Corps members)

1st Reference

1st Reference Name *

First

Last

1st Reference Address *

Line 1

Line 2

City

State

Zip Code

Country

1st Reference Phone *

2nd Reference

2nd Reference Name *

First

Last

2nd Reference Address *

Line 1

Line 2

City

State

Zip Code

Country

2nd Reference Phone *

How did you hear about us? *

By who were you referred to PCVAC? *

Do you drive? *

Yes No

Has your license been suspended or revoked? *

Yes No

Have you been convicted of a crime, other than traffic violations? *

Yes No

Have you ever been a member of PCVAC or any other ambulance agency? *

Yes No

If yes, which agency? *

Training or Experience
Do you have any of the following?

Have CPR Certification? *

Yes No

Have First Aid Certification? *

Yes No

Have EMT Certification? *

Yes No

I declare, subject to the penalties of perjury, that the above statements made in this application have been examined by me and to the best of my knowledge are true and accurate. *

Yes

Application for Membership

Adult Corps

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