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Online Application THIS FORM IS NOT WORKING TEMPORARILY
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 Type CFR EMT-B EMT-I EMT-CC Paramedic
Certification Number:
Expiration Date: (mm-dd-yyyy)

 

Membership Information
Type of Membership:	Type of Membership Senior Membership - Persons 18 or older Junior Membership - Under 18

 

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?	Yes No

 

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.