Name:			Birth Date:	mm/dd/yyyy
Address:			Phone:	xxx-xxx-xxxx
Address2			E-Mail:
City			State ZIP

Social Security Number Occupation   Hrs of emp

Employer:

Address: Phone Number: xxx-xxx-xxxx

City:     State:     Zip:

Driver License Number:  Expiration Date mm/dd/yyyy

Education Completed:   Best Time for Interview

Military Service: no   yes  Branch:

List First-Aid certificates that you now hold:

Type Yes or No to the following questions

Are you attending or plan to attend school?

Are you in possession of a valid NJ License?

Has your Drivers License ever been Suspended or Revoked?

Have you ever Been Involved in any Moving Violations?

Have you ever been Convicted of a crime?

Have you ever been Bonded or refused Bond?

References: Please list 3 character references other than relatives

Name	Address	Phone Number
		xxx-xxx-xxxx
		xxx-xxx-xxxx
		xxx-xxx-xxxx

Investigation Committee Information

List any Organizations that you belong to:

Organization Name	Offices Held	Membership timeframe

Why do you wish to join Haledon Emergency Ambulance Association (HEAA)?

Would you be willing to hold office in HEAA? yes

When are you available for duty?

	Sun.	Mon.	Tues.	Wed.	Thur.	Fri.	Sat.
Days:
Evenings:

Will you be able to attend the necessary business meetings? (1st Monday of every month) Yes

Type Yes or No to the following questions

Have you ever had an Alcohol Problem?

Have you ever had a drug problem?

Do you take medications regularly? If so, please list..

By clicking on the Submit Application  button below, you certify that all of the information is correct. That all answers given on the application are true to the best of your knowledge and belief. It is understood that any false statement on this application or to the investigation committee is sufficient cause for rejection or dismissal of said application.

This application will be reviewed by the  Haledon Emergency Ambulance Association. If you do not receive a response from us within 2 weeks, please contact the Squad at (973) 423-0141. You may also print this form and mail to:

Chief
Haledon Emergency Ambulance Association
P.O. Box 8027
Haledon, NJ 07538

Click here for Medical Release Form   

          

Thank You!

Click here to go to HEAA home page