Personal Information:

Full Name:

Address:
  
Town: State:   Zip:

Phone Numbers
Home: Work: Cell:

Email Address: (Must be Valid) 

Date of Birth:

Your availability:

Are you available Weekdays?  Select Yes No Often/Usually Sometimes/Rarely

Are you available Weeknights? Select Yes No Often/Usually Sometimes/Rarely

Are you available Weekend Days? Select Yes No Often/Usually Sometimes/Rarely

Are you available Weekend Nights? Select Yes No Ofte/Usually Sometimes/Rarely

Emergency Medical Training Information:

Certification/Licensure level (Must be active in CT):  EMT-B EMT-I Paramedic

Exp. Date:
  

CPR Exp. Date:

Paramedics Only Complete this Section:

Do you currently hold Medical Control with a North Central Connecticut Region Sponsor Hospital?
Select YES NO

Please list the dates, regions and sponsor hospitals you held medical control authorization in:

All Applicants complete:

Past Experience (Places you have been a part of EMS, Including hospital, fire department etc.)

Background Questions:

Do you have any medical conditions that would hinder your ability to perform the duties of an ambulance technician? YES NO

Have you ever been convicted of a felony? YES NO

Have you ever been, or are you currently, addicted to any illegal drugs or alcohol that would hinder your ability to perform the duties of an ambulance technician?  YES NO

If you answered YES to any of the above questions, please explain in detail:

Driver Information/History:

Have you had any motor vehicle violations in the last 5 years? YES NO

Have you EVER had any motor vehicle related arrests and/or convictions? YES NO

Have you EVER been in a motor vehicle collision, regardless of fault? YES NO

If you answered YES to any of the above questions please explain in detail:

References:

Name:
  
Phone:

Address:
  
City: State: Zip:
    
Relationship to you:

Name:
  
Phone:

Address:
  
City: State: Zip:
    
Relationship to you:

Name:   

Phone:

Address:
  
City: State: Zip:
    
Relationship to you:

Authorization:

I hereby certify that the statements I have made on this application are true to the very best of my knowledge.  I authorize the East Windsor Ambulance Association Inc. to verify any statements I have made on this application.  I understand that any misrepresentations made by me on this application will constitute grounds for denial of membership, or grounds for termination if you were hired.

Please Type your Full name:
By typing your name in the above box, you are effectively signing this form.  Your name in the box above signifies you understand that it constitutes as your signature.