East Windsor Township Rescue Squad, District 1 Inc.

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Membership Application
NOTE*	ALL INFORMATION HEREIN WILL BE HELD CONFIDENTIAL
Name (Last/First/Middle)*
StreetAddress*
City*
State*
Zip Code*
Phone Number (Home)*
Phone Number (Daytime)*
Emergency Contact (Name/Address/Phone/Relation)*
Age*
Birthdate (mm/dd/yyyy)*
Social Security Number*	WILL BE MANDATORY UPON ACCEPTANCE OF MEMBERSHIP APPLICATION
How long have you resided at your current address?*
List All First-Aid/Rescue Training (Including Dates)*
Have you ever been a member of a first aid, ambulance or Rescue Squad?*	Yes No
If Yes, Name of organization, Dates of memberhip (Note any offices Held)*
Were you rejected or dismissed by any if the above?*	Yes No
If Yes, Please Explain:*
Occupation*
Employer and Mailing Address*
Do you have any physical/mental conditions that would impair your ability to perform on a crew?*	Yes No
If yes, Please Explain*
Have you ever been convicted of a crime?*	Yes No
If yes, Please Explain:*
Do you have a valid Driver's License*	Yes No
State/Drivers License Number (Enter Both)*
How long have you had your Driers License?*
Has your License Been revoked or suspended in any state?*	Yes No
If yes, Please Explain:*
REFERENCES*	It is necessary for you to provide two letters of reference from non-family members. The letters must include: the person's name, phone number, address, and length of time that he/she has known you. (This application will not be considered without these letter
Membership Requested*
Ambulance*	Yes No
Heavy Rescue (age 18 and older only)*	Yes No
Associate (non-riding member)*	Yes No
Cadet (age 14-18)*	Yes No
Are you available to participate in squad assignments/activities on nights and weekends?*	Yes No
Are you willing to accept assignments on an equitable basis with other members*	Yes No
Why do you seek to join and participate with the East Windsor Township Rescue Squad District #1*
NOTE*	By Clicking Submit, I represent that the statements made above are complete and truthful. I understand and agree that if approved as a member, the Constitution and By-Laws and other official regulations of the East Windsor Rescue Squad District #1, Shall be binding

* : The element is required