Application for Membership

Please complete the following form and someone will contact you to set up an interview.

Indicates Required Field

Personal Information
Name: Please list your legal name, (Last, First, M.I.)
Address: Please list you current residence
Phone: Please list the best number at which to reach you.
Email: Please list an email address at which you can be reached
How long have you lived at the above address: Years/Months
Are you 18 years of age or older?:		Yes No
Do you have a valid NYS Driver's License?:		Yes No
General Availability
Weekday Availability:		Both Weekdays and Weeknights Weekdays Only Weeknights Only Not Available During Week
Weekend Availability:		Both Weekend Days and Nights Weekend Days Only Weekend Nights Only Not Available Weekends
Prior Experience
Do you have any previous emergency services experience?:		Yes No
If yes, please list the organization and a contact name/number for that organization: