TVAC- Application

Join

	What Members Do
	Responsibilities
	Application Form

TVAC Application
Name:	(First Last)
SS#:	(xxx-xx-xxxx)
Street Address:
City:
State:
Zip Code:
E-mail:
Contact Phone:
List any previous addresses for the last 5 years

Occupation:
Employer/School:
Their phone:
Their address:
Name of a person at job whom we can call as a reference:
Their Phone:
Highest level of education:
Have you ever served in the military:	Yes No
If yes:	Nation: Branch: Date - From: Date - To:
Drivers license state:
Drivers license #:
List accidents and violations over past 5 years:
Have you been convicted of a crime:	Yes No
If yes:	Date: Location: Description:
Have you ever been refused a bond:	Yes No
Have you ever been a member of a paid or volunteer Emergency Service:	Yes No
If yes:	Name of Squad: Phone of Squad: Dates of Service:
Do you have CPR training:	Yes No Exp. Date:
Are you an EMT:	Yes No Exp. Date:

When can you ride?	(Four hours per week required, if you are not sure, please leave this section blank and we will discuss it with you)
Weekday (4 hours any time between 7 AM & 7PM)	First choice: Second Choice: Third Choice:
Evening (Any night 7PM-11PM)	First choice: Second Choice: Third Choice:
Overnight (Sleep here 11PM-7AM, any night)	First choice: Second Choice: Third Choice:

References	Please list names, addresses, and phone numbers of three people who will vouch for your good character. Please do not list relatives.
Reference One:
Reference Two:
Reference Three:

Please write a brief sentence or two about why you wish to join TVAC:

Legal Stuff	Please "sign" this legal declaration by entering your initials into the field below.
Initials:	"I certify that the above information is true and complete to the best of my knowledge, I promise that if I become a member, I will abide by the rules and regulations of the NJ Dept. of Health and the Teaneck Volunteer Ambulance Corps."