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: Are you attending or plan to attend school? Yes No Are you in possession of a valid NJ License? Yes No Has your Drivers License ever been Suspended or Revoked? Yes No Have you ever Been Involved in any Moving Violations? Yes No Have you ever been Convicted of a crime? Yes No Have you ever been Bonded or refused Bond? Yes No 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 Have you ever had an Alcohol Problem? Yes No Have you ever had a drug problem? Yes No Do you take medications regularly? Yes No By signing 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. ____________________________________________ Signature of Applicant Print this form and mail to: Chief Haledon Emergency Ambulance Association P.O. Box 8027 Haledon, NJ 07538 Click here for Medical Release Form This application and medical release will be reviewed by the Haledon Emergency Ambulance Association. If you do not receive a response from us within 2 weeks of your mailing us both forms, please contact the Squad at (973) 423-0141. Thank You! Click here to go to HEAA home page
References: Please list 3 character references other than relatives
Investigation Committee Information
List any Organizations that you belong to:
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?
Will you be able to attend the necessary business meetings? (1st Monday of every month) Yes
Have you ever had an Alcohol Problem? Yes No
Have you ever had a drug problem? Yes No
Do you take medications regularly? Yes No
By signing 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.
____________________________________________ Signature of Applicant
Print this form and mail to: Chief Haledon Emergency Ambulance Association P.O. Box 8027 Haledon, NJ 07538
Click here for Medical Release Form
This application and medical release will be reviewed by the Haledon Emergency Ambulance Association. If you do not receive a response from us within 2 weeks of your mailing us both forms, please contact the Squad at (973) 423-0141.
