BAY RIDGE RESCUE SQUAD
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ONLINE APPLICATION
BUILDING USE APPLICATION
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BAY RIDGE RESCUE SQUAD, INC.
1109 Ridge Road, Queensbury, NY 12804
Online Application
TYPE OF APPLICATION
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Indicates required field
What Are You Applying For?
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JUNIOR SQUAD
VOLUNTEER
*SOCIAL MEMBER*
PAID STAFFING
CURRENT CERTIFICATIONS
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NONE
CPR CERTIFIED
EMT CERTIFIED
AEMT CERTIFIED
CCT CERTIFIED
PARAMEDIC CERTIFIED
ADDITIONAL CERTIFICATIONS
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Applicant Information
Name
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First
Last
Date Of Birth
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Phone Number
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Cell Carrier Company
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Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Social Security Number (PAID STAFF ONLY)
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Drivers License Number
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State & Expiration Date
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Emergency Contact
Name
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Relation
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Address
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Phone Number
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References
1. Name
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Phone Number
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Known How Long?
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2. Name
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Phone Number
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Known How Long?
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3. Name
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Phone Number
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Known How Long?
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Employment History
1. Name of Employer
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Job Title
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Supervisor
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PHONE NUMBER
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How been employed and reason for leaving (If applicable)
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2. NAME OF EMPLOYER
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JOB TITLE
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SUPERVISOR
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PHONE NUMBER
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How been employed and reason for leaving (If applicable)
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3. NAME OF EMPLOYER
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JOB TITLE
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SUPERVISOR
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PHONE NUMBER
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How been employed and reason for leaving (If applicable)
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4. EMPLOYER NAME
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JOB TITLE
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SUPERVISOR
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PHONE NUMBER
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How been employed and reason for leaving (If applicable)
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Questionaire
Do you now have any physical, mental, emotional or nervous conditions, diseases or disabilities that may affect your ability to perform duties in this Rescue Squad?
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YES
NO
Have you ever been convicted of any crimes at any level?
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YES
NO
If YES, please explain:
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If YES, please explain:
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Do you have any pending criminal court cases?
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YES
NO
Do you have any points on your driving record?
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YES
NO
If YES, please explain:
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IF YES, PLEASE EXPLAIN:
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ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF ANY OTHER EMS/FIRE AGENCY?
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YES
NO
IF YES, PLEASE LIST
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IF NOT CERTIFIED, WHICH EMS COURSES WOULD YOU LIKE TO TAKE?
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EMR
EMT
AEMT
NONE
IF YOU CHOSE NONE, PLEASE EXPLAIN:
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DO YOU POSSESS ANY SKILLS THAT WOULD BENEFIT AND BE HELPFUL TO THIS ORGANIZATION?
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PLEASE READ CAREFULLY:
The Bay Ridge Rescue Squad Inc. prides itself on accepting applications for Volunteering & Paid Staffing regardless of an applicant's race, color, creed, sex, marital status, disability, national origin, ancestry or place of birth.
I hereby apply for
Volunteer Status or Paid Staffing
membership in the Bay Ridge Rescue Squad Inc. I understand that my acceptance in the corporation will be on a six month probationary basis. During which time my status may be terminated in accordance with the corporation by-laws or New York State Labor Laws. Any false statements or omissions made in this application will be considered sufficient cause for expulsion from the corporation upon discovery thereof.
I hereby authorize Bay Ridge Rescue Squad Inc. or its representatives to make official inquiry of all persons, public and private companies, corporations, consumer reporting agencies, law enforcement agencies, state licensing and certifying agencies and medical advisors of this corporations to supply all information concerning my character, current and prior employment or membership verification, general reputation, personal characteristics and mode of living and furnish reports thereon.
If I am accepted as a Volunteer or Paid Staff for the Bay Ridge Rescue Squad Inc., I will follow the operating rules as adopted and the by-laws as they may be amended in the future. I will agree to submit to physical and medical examinations at the option and expense of the corporation and also agree that the examining physician will disclose to the corporation or its representatives, the results of such examinations.
PLEASE SIGN TO SHOW ACKNOWLEDGEMENT. (You may have to sign a paper form during interview.)
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date of acknowledgement:
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DISCLOSURE & RELEASE
In connection with my application for membership or employment (including contract for services) with the Bay Ridge Rescue Squad Inc., I understand that consumer reports, which may contain public record information, may be requested and obtained. These reports may include information related to my previous driving record including court actions, citations, license suspensions and revocations as well as checking the NYS Sex Offenders Registry.
I HEREBY AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED TO FURNISH THE ABOVE MENTIONED INFORMATION
I have the right to obtain information as to the name, address and phone number of any agency providing such information and further, may request of that agency, upon proper identification, the nature and substance of all information in its files on me at the time of my request, including all sources of information, as well as, the recipients of any reports on me which that agency has previously furnished within the two (2) year period preceding my request.
This authorization shall remain on file and shall serve as ongoing authorization for the organization to procure Motor Vehicle Reports at any time during my employment, membership or contract period.
PLEASE SIGN TO SHOW ACKNOWLEDGEMENT. (You may have to sign a paper form during interview.)
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date of acknowledgement:
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Submit