-.Medford Volunteer Ambulance, Inc.1005 Sipp Avenue

Medford, NY 11763-3640(631) 758-3534 • Fax (631) 477-2717

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Application for Membership

Name:

Address:City: ST: Zip:

Telephone: Home: Cell:

Social Security Number:

Employment History ( Newest first, Left to right )

Employer: Employer:

Address: Address:ST: ZIP: ST: ZIP:City: City:

Phone Number: Phone Number:

Occupation: Occupation:

Currently Employed? Currently Employed?

Employment Dates: to Employment Dates: to

Supervisor: Supervisor:

Reason Left: Reason Left:

Employer: Employer:

Address: Address:ST: ZIP: ST: ZIP:City: City:

Phone Number: Phone Number:

Occupation: Occupation:

Currently Employed? Currently Employed?I

toEmployment Dates: Employment Dates: toSupervisor: Supervisor:

Reason Left: Reason Left:1

Yes No Yes No

Yes No Yes No

Medford Volunteer Ambulance, Inc.1005 Sipp Avenue

Medford, NY 11763-3640(631) 758-3534 - Fax (631) 477-2717

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III

Organization History ( Newest first, left to right )

Please list all past Fire Departments or Ambulance Companies you have belong/belonged to: Besure to write full address to prevent delay in mailing. i

Organization: Organization:

Address: Address:ZIP:ST: ST: ZIP:City: City:

Phone Number: Phone Number:

Occupation: Occupation:

Member Currently? Member Currently?

toMembership Dates: Membership Dates: to

President/Chief.- President/Chief:

Reason Left: Reason Left:I

Organization: Organization:

Address:Address: ?,F

ZIP:ST: ST: ZIP: iCity: City:I

Phone Number: Phone Number:

Occupation: Occupation:

Member Currently? Member Currently?

toMembership Dates: Membership Dates: to

President/Chief: President/Chief.

Reason Left: Reason Left:

2

Yes No

Yes No

Yes No

Yes No

Medford Volunteer Ambulance, Inc.1005 Sipp Avenue

Medford, NY 11763-3640(631) 758-3534 - Fax (631) 477-2717

References

List the names of three (3) persons who haveknown you for at least one year

Name:

Address:ZIP:ST:Must be non-family and ones not affiliated

with Medford Vol. Ambulance, include a fullCity:

Phone Number:address to avoid any delay in your.application. Years Acquainted:

Name: Name:

Address: Address:

ST: ST:City: ZIP: City: ZIP:

Phone Number: Phone Number:

Years Acquainted: Years Acquainted:

Certifications

Type: License #

Type: License #

License #Type:

Education (Newest First)

3

Name ofSchool

YearsAttended

DegreeAttained

Medford Volunteer Ambulance, Inc.1005 Sipp Avenue

Medford, NY 11763-3640(631) 758-3534 - Fax (631) 477-2717

Applicant's Consent to the Release of Information

Name:

Address:

ST:City: ZIP:

Telephone: Home: Cell:

Your signature on this form authorizes Medford Volunteer Ambulance, Inc to obtain employee and

reference information from all current and past employers as well as from all references obtained

from the person signing this authorization.

The consent granted by this form may be used to collect sensitive information which is protected

by the Privacy Act. Such information will not be disclosed outside of Medford Volunteer

Ambulance, Inc.

I agree that photocopies of this authorization may be used for the purpose stated above. I

understand if I fail to sign this authorization, this action may constitute grounds for denial of

eligibility into Medford Volunteer Ambulance, Inc.

Signature of Applicant:

Dated:

4

Medford Volunteer Ambulance, Inc.1005 Sipp Avenue

Medford, NY 11763-3640(631) 758-3534 - Fax (631) 477-2717

I hereby authorize Suffolk County Police Department to do an arrest record check on me, andauthorize the release of said information directly to Medford Volunteer Ambulance, Inc.

Dated:

Applicant's Name:

Address:

ST: ZIP:City:

Social Security Number:

DOB:

Applicant Signature:

State of New York)County of Suffolk)

personally appearedI do hereby state that

20day ofbefore this

Notary Signature: Date of Expiration:

Notary Stamp:

**(This form and consumer form only to be signed afterapplicant meets with and is accepted by Officers)

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To Whom It May Concern:

Medford Volunteer Ambulance, Inc.1005 Sipp Avenue

Medford, NY 11763-3640(631) 758-3534 - Fax (631) 477-2717

DISCLOSURE & AUTHORIZATION FORM FOR CONSUMER REPORTS

This serves to advise you that in consideration for employment (including contract for services) with Medford Volunteer Ambulance aconsumer report and/or investigative consumer report may be obtained on you. This process may include verification of education, credithistory, employment history, a review of any local, county, state, and federal government agency records, court public records, drivingrecords (MVR), workers' compensation claim files, and employment, personal or professional references. References may includeinformation pertaining to your general character and reputation, personal characteristics, mode of living, and work habits. A consumerreport containing injury and illness records and medical information may be obtained after a tentative offer of employment has been made.The source of the reports will be First Advantage, 300 Primera Blvd., Suite 356, Lake Mary, FL 32746. Toll-free number: 800-725.5051 ext:122.

Please be advised you have the right to inspect the files that the consumer reporting agency may have on YOU during normal businesshours and upon furnishing proper identification. You also have the right to make a request of First Advantage, upon properidentification and the payment of any authorized fees, for the information in its files on you at the time of your request. The natureand scope of the investigative consumer report will be social security verification, employment check, workers coup claims, driving record,criminal checks, nationscan, and sex offender registry the will be obtained for the company's use for employment purposes. Before anyadverse action is taken, based in whole or in part on the information contained in the consumer report, you will be provided a copy ofthe report and a summary of your rights under the Fair Credit Reporting Act, as well as additional information on your rights under thelaw.

By signing below, you hereby authorize without reservation, any party or agency contacted to furnish the above mentioned information.You further authorize ongoing Procurement of the above mentioned reports at any time during Your employment (or contract). You alsoagree that a fax or photocopy of this authorization with your signature be accepted with the same authority as the original.

You hereby authorize and request, without any reservation, any present or former employer, school, law enforcement or criminal agency,financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about you tofurnish First Advantage with any and all background information in their possession regarding you, in order that your employmentqualifications may be evaluated.

For California, Minnesota or Oklahoma applicants only, if you would like to receive a copy of the consumer report as prepared by theconsumer reporting agency, if one is obtained, please check this box and we will send a copy to you within three days.

If Public record information about your character, general reputation, personal characteristics, and mode of living is obtained withoutusing a consumer reporting agency, you will be supplied a copy of the public record information within seven days of our receipt of itunless you check this box where you hereby waive your right to obtain a copy of the consumer report.

Printed Full Name Home Phone Work Phone

Date of BirthYear last usedSocial Security Number Maiden or other name used

Drivers License Number

Signature Date Signed

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State