AMERICAN LEGION AMBULANCE SERVICE
A Subsidiary of American Legion Post 1363
17 Collins Road, PO Box 63
Eldred, NY 12732
APPLICATION FOR MEMBERSHIP
Name:_____________________________________________
Address:___________________________________________
Phone No:___________________________
Social Security No:____________________
Date of Birth:_________________________
Drivers License No:________________________________ I hereby consent to allowing ALAS to check my driving record with the NYS Dept. of Motor Vehicles.
Medical Training: (Give Type: First Aid, CPR, EMT with expiration date & No.) ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Reason for wanting to join Ambulance Corps:_______________________________
____________________________________________________________________
Any Physical Impairments:(Back condition, Heart, etc.)_______________________
____________________________________________________________________
____________________________________________________________________
Time of day you are customarily available:__________________________________
Occupation:___________________________________________________________
Place of Employment:___________________________________________________
Address:______________________________________________________________
If you are employed in the Town of Highland area, will your employer allow you to respond to emergency calls during working hours? (Yes or No)___________________
References: (List 3 non-family) 1.___________________________________________
2.__________________________________3._________________________________
I affirm that in accordance with requirements of 10NYCRR Part 800.8(e), I have not been convicted of or am not currently charged with any misdemeanors or felonies. I understand that if I have a conviction it will be individually reviewed and that any such conviction may not be an automatic bar to certification and that the Dept. of Health will determine if it is applicable.
If accepted into membership, I hereby agree to adhere to all policies, procedures, protocol and rules and regulations as may be set forth by the American Legion Ambulance Services and/or the American Legion Post 1363, and I further understand that there is a probationary period of one year following acceptance:
Date:_____________________ Signature:_________________________________
