| Contact Info | Learn CPR | Join Us! | Donate | Photos |
|---|---|---|---|---|
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Online Application THIS FORM IS NOT WORKING TEMPORARILY |
| Drivers License | |
| License #: | |
| State of Issuance: | |
| Expiration: (mm-dd-yyyy) |
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Emergency Contact Info |
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| 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 |
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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.