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Cochecton Volunteer Ambulance Membership Application
I hereby make application for Active road membership to the Cochecton Volunteer Ambulance Corps. As a condition for acceptance of this application, I agree to abide by, and comply with, the constitution, bylaws, and standard operating procedures of the Cochecton Volunteer Ambulance Corps, all of which I may review at any time by request to a CVAC officer.
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Full Name
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Today's Date:
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YYYY
Full Address
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Phone Number
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Email Address
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Date of Birth
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YYYY
Referred By:
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Driver's License (State and Number)
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Any EMS Certifications e.g. CPR, EMT etc.. Please include expirations dates.
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Please list 2 character references that we may contact. Include name, address, phone number, and relation.
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Have you ever been arrested? If yes, briefly explain:
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Have ever been convicted or pled guilty to any crimes?
If yes, briefly explain:
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Driving history: any tickets or violations in past 3 years?
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Acceptance and Acknowledgment
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I attest above statements are true. I also give permission to Cochecton Volunteer Ambulance Corps to run a driver and criminal background check at their expense.
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