Name (Last, First, MI)**:

Nickname:

DOB:

Address**:

City:

State: Select one... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Home Phone**: ex: 555-555-5555

Work Phone: ex: 555-555-5555

Cell Phone: ex: 555-555-5555

Email:

Pager: ex: 555-555-5555

Secondary Email:

Spouse's Name:

Complete this section only if you are under 18 years of age. Minimum membership age is 16 years old.

Name:

Relationship:

Address:

City:

State: Select one... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Complete this section only if you seek to drive an ambulance

NYS License Number:

Class:

License Exp Date:

Number Years Licensed:

Conditions / Restrictions: Yes No

If Yes, Explain

Conditions / Restrictions: Yes No

If Yes, Explain

Defensive Driving Training: Yes No

Date:

Emergency Vehicle Operation Training: Yes No

Date:

Do you have any physical or medical conditions / impairment / medications, which may affect your ability to perform in strenuous activity as required in emergency medical services work?: Yes No

If Yes, Explain

Have you applied to PVEA previously?: Yes No

If Yes, When

List any previous EMS affiliations. (Use full name, no initials):

Current certification level - NYS EMT: Basic Intermediate Critical Care Paramedic

Expiration dates:

NYS Certified First Responder (CFR):

Emergency Response Course (American Red Cross):

Responding to Emergencies (American Red Cross):

CPR (ARC or AHA):

Additional Training:

Do not list persons related to you or your current employer. Give complete mailing addresses and indicate if phone number is home or work. Please list 3 references.

Reference 1

Name:

Phone Number: ex: 555-555-5555

How acquainted:

How long have you known this person:

Address:

City:

State: Select one... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Reference 2

Name:

Phone Number: ex: 555-555-5555

How acquainted:

How long have you known this person:

Address:

City:

State: Select one... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Reference 3

Name:

Phone Number: ex: 555-555-5555

How acquainted:

How long have you known this person:

Address:

City:

State: Select one... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Company name:

Business phone number: ex: 555-555-5555

Occupation:

How long employed:

Supervisor's name:

Supervisor's phone number: ex: 555-555-5555

Address:

City:

State: Select one... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Have you ever been convicted of a felony or misdemeanor?: Yes No

If Yes, please explain:

I hereby state that all of the above questions have been answered truthfully and without gross omission. I authorize PVEA to check my references and/or all of the above with the proper law enforcement agency. I also understand that willful falsification or omission from this application will be cause for rejection or dismissal. It is furthur understood that this application will be handled in accordance with the Civil Rights Act of 1964 and no discrimination will occur because of age, sex, religion, race or national origin.