Personal Information:

Full Name:

Address:
  
Town: State:   Zip:

Phone Numbers
Home: Work: Cell:

Email Address: (Must be Valid) 

Date of Birth:

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:

Please Answer the Following Questions:

What are your future goals?

Why do you wish to become EMT Certified?

What are your best and worst traits, and why?

References:

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 disqualification from the scholarship application process.

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.