East Windsor Township Rescue Squad, District I

Membership Application

Name*
FirstLast
Address*
Street AddressAddress Line 2CityStateZip Code
Age
Please enter a value between 14 and 99.
Date of Birth*
Email*
How long have you lived at your current address?
Emergency Contact Information
Emergency Contact
FirstLast
Emergency Contact Address
Street AddressAddress Line 2CityStateZip Code
Emergency Contact Phone
Prior Training
List all first aid training (Include Dates)
List all certifications and classes, one per line.
Have you ever been a member of a first aid, ambulance or rescue squad?*
- Yes
- No
Name of Organization, Dates of Membership, note any offices held.
Were you rejected or dismissed by any of the above?*
- Yes
- No
Explain:
Personal Information
Occupation
Employer
Employer Address
Street AddressAddress Line 2CityStateZip Code
Do you have any physical/mental conditions that would impair your ability to perform on a crew?*
- Yes
- No
Explain
Criminal and Driver history
Have you ever been convicted of a crime?*
- Yes
- No
Explain
Do you have a valid NJ driver's license?*
- Yes
- No
How Long
Driver License Number
Have your driving privileges ever been revoked or suspended in this or any other state?*
- Yes
- No
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, address, phone number and length of time he/she has known you. This application cannot be considered without these letters.

You may upload reference letters below, or have them emailed to exec@squad142.com
Reference 1
Reference 2
Membership
Membership Requested*
- Ambulance
- Rescue
- Associate
- Cadet
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 in the activities of the East Windsor Township Rescue Squad, District 1?*
ALL ABOVE INFORMATION WILL BE HELD CONFIDENTIAL

I represent that the statements made herein are complete and truthful. I understand and agree that if approved as a member, the Constitution,By-Laws and other regulations of the East Windsor Township Rescue Squad, District 1, shall be binding.
Date signed*
Name*

Pages

Contact Us
Executive Board
- Contact The Executive Board
Line Officers
- Contact The Line Officers
Membership Application