Online Application

Online Application Disclaimer:

By submitting this online application you are agreeing to the following:

I hereby represent and warrant that the answers to the below questions are true and correct and are given the purpose of securing the active/junior membership with Tri-Community Ambulance Service, Inc. If my application is approved, I hereby agree to abide by the constitution, and Bylaws, and Standard Operating guidelines of Tri-Community Ambulance. This application must be approved at the regular monthly membership meeting following the receipt of this application.

I also certify that I have never been charged or convicted of a felony. Failure to be truthful will be grounds for immediate dismissal. I authorize Tri-Community Ambulance Service, Inc. to obtain an investigative criminal record search, motor vehicles records search, and registered sex offender search before membership is granted and any time during my membership. This investigation is completely confidential.

I hereby hold Tri-Community Ambulance Service, Inc. free and harmless of any liability for any damages arising out of any improper use of this information.

If applying for Active membership, can you meet all the job qualifications for a Basic Emergency Medical Technician, as stated by the New

York State Department of Health? A Copy of the job description can be viewed online at the following site:

http://www.health.state.ny.us/nysdoh/ems/pdf/srgemt.pdf

or TCAS can provide you with separate document at request.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to membership, I understand that false or misleading information in my application or interview may result in my dismissal from the company.

I understand that there is a non-refundable $10.00 application fee and can be made via Cash, Check, or Venmo - Venmo - @TriCommunity-Ambulance or Check can mailed to PO Box 241 Sanborn, NY 14132 or can setup payment arrangements during my phone interview.

I also understand that Tri-Community Ambulance is a volunteer organization however standards are very high and require members to conduct themselves as professional. I also understand that I am required to give 12 hours of service a month.

Online Application for Membership

Name*

Email Address*

Phone*

Mailing Address *

City *

State *

Zip Code *

Membership Applying for*

Are you a citizen of the United States?*

Have you even been a member before? **

Are you over the age of 18? *

Do you currently have any NYS DOH Certifications? **

Have you ever been a member of any Fire or Ambulance company in the past?*

Name(s) of Fire/Ambulance Company if applicable

Current Employer*

Personal Reference - Name and Phone Number *

Professional Reference - Name and Phone Number*

My we conduct a background check?*

If applying for Active membership, can you meet all the job qualifications for a Basic Emergency Medical Technician, as stated by the New York State Department of Health? A Copy of the job description can be viewed online. http://www.health.state.ny.us/nysdoh/ems/pdf/srgemt.pdf*

Yes

DISCLAIMER AND SIGNATURE We understand that this is a volunteer organization however our standards are extremely high and require us to conduct ourselves as professionals. I hereby represent and warrant that the answers to the above questions are true and correct and are given for the purpose of securing membership in Tri-Community Ambulance Service, Inc. If elected to membership, I hereby agree to abide by the constitution, By Laws and regulations of Tri-Community Ambulance Service, Inc. I also certify that I have never been charged & convicted of a felony. Failure to be truthful will be grounds for immediate dismissal. This application must be approved at the regular monthly membership meeting following the receipt of this application. I authorize Tri Community Ambulance Service Inc to obtain an investigative criminal record search, motor vehicle records search and registered sex offender search before membership is granted and at any time while I am a member. I authorize the release of information from previous or current employers and references. This investigation is strictly confidential. This report contains information compiled from sources believed to be reliable, but the accuracy of which cannot be guaranteed. I hereby hold Tri Community Ambulance Service Inc free and harmless of any liability for any damages arising out of any improper use of this information. I certify that my answers are true and complete to the best of my knowledge. Tri-Community Ambulance prohibits discrimination against its members, and applicants for membership on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, and sexual orientation. If this application leads to membership, I understand that false or misleading information in my application or interview may result in my dismissal from the company. I also understand that there is a $10.00 non-fundable application fee that is due at the time this application is submitted. Fee can be paid via Cash, Check, or Venmo @TriCommunity-Ambulance I also understand that if I do not complete a new member orientation within 3 months of date application is accepted that I will be dropped from the company roles and must reapply. I also understand all the requirements for membership and that I will be in probationary status for 6 months.

Disclaimer*

Yes I agree with above disclaimer

No I do not agree

Signature (Please Type Full Name)*

Today's Date *