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Online Application

Personal Information  
Name:
Address:
Apt:
City:
State:
Zip:  
Home Phone: (xxx-xxx-xxxx)
Cell Phone: (xxx-xxx-xxxx)
E-Mail Address:
Last 4 of Social Security #:  
Birth Date: (mm-dd-yyyy)

 

Drivers License  
License #:
State of Issuance:
Expiration: (mm-dd-yyyy)

 

Emergency Contact Info

  
Contact Name:
Relationship:
Contact Phone: (xxx-xxx-xxxx)

 

Certifications (if applicable)  
CPR Expiration Date: (mm-dd-yyyy)
First Aid Expiration Date: (mm-dd-yyyy)
Type of Certification:
Certification Number:
Expiration Date: (mm-dd-yyyy)

 

Membership Information  
Type of Membership:

 

Occupation  
Occupation:
Employer:
Address:
City:
State:
Zip:
Phone: (xxx-xxx-xxxx)

 

Prior EMS Experience  
Name of Agency:
Contact Person:
Contact Phone: (xxx-xxx-xxxx)

 

References  
Name:
Phone: (xxx-xxx-xxxx)  
   
Name:
Phone: (xxx-xxx-xxxx)
   
Name:
Phone: (xxx-xxx-xxxx)
   
Do you know any LVAC members?

 

Additional Information:  
 
Have you ever submitted an application to LVAC before?

 

Felony  
If you have ever committed a felony, please describe here

Waiver

By submitting this form I herby give permission to the Town of Mamaroneck/ Village of Larchmont Volunteer Ambulance Corps to verify information concerning my character and advise you thereof for the purpose of becoming a member of the Town of Mamaroneck/ Village of Larchmont Volunteer Ambulance Corps.  A routine inquiry may be made into this application to provide us with information concerning your personal character.  It is also noted that if I am under 18 years of age my parents or legal guardians approve of this application.

I understand that any false statements made hereon will automatically disqualify me from membership in the Town of Mamaroneck/ Village of Larchmont Volunteer Ambulance Corps.