Tabernacle Rescue Squad, Inc. - Station 439
Membership Application


Type of Membership Request: *

Name: *
Address: *
Address 2:
City: *
State: *
Zip Code: *
How long have you resided at this address? (years) :

Date of Birth: *
Social Security Number: *

Home Phone (If none, enter mobile phone): *
-
Mobile Phone:
-
Alternate Phone:
-
E-mail: *
Which Phone Number should we contact?: *
When is the best day and time to contact you?: *
If other, please specify:
Do you currently have a valid driver's license issued by the State of New Jersey?: *
Driver's License Number: *
DL Expiration Date: *
Do you have any endorsements on your license? (Check all that apply): *
How long have you been driving?: *

Have you had any accidents or violations in the past three (3) years?: *
If yes, How many accidents?:
If yes, Please explain each accident and the circumstances involved:
If yes, How many violations? (moving and non-moving):
If yes, explain each violation and the circumstances involved:
Has your Driver's License ever been suspended or revoked?: *
If yes, please explain each suspension or revocation and the circumstances involved:

How many points do you currently have on your driver's license?:

Do you require any corrective devices? (Check all that apply): *

You must answer the following questions below. Any arrest, conviction, suspension, revocation, etc., may not exclude you from joining as a member of the Tabernacle Rescue Squad. However, falsifying or omitting any information on this application will be grounds for a rejection of your application or immediate removal from the Tabernacle Rescue Squad.

Question 1: (Two Part Question)

a) Have you ever been arrested for a crime, regardless of conviction, which has not been annulled, expunged, or sealed by the court? (b) Have you ever been convicted of any crime, excluding minor traffic offenses, which have not been annulled, expunged or sealed by the court?: *
If yes, explain in detail any arrest or conviction in detail:

Question 2:

Have you ever had any of your professional license(s) suspended or revoked?: *
If yes, please explain in detail:

Questions 3:

Have you ever been excluded, suspended, or debarred from the Medicare or Medicaid programs or any other federally funded health care program, or had civil monetary penalty or administrative fine imposed against you?: *
If yes, please explain any in detail:

Question 4:

Do you have any medical, mental, or physical conditions that would prohibit you from joining the Tabernacle Rescue Squad?: *
If yes, please explain any conditions in detail:
Are you CPR/AED Certified at the Professional Rescuer level?: *
If yes, What is your CPR expiration date?:

Are you certified as an Emergency Medical Techincian, able to practice in the State of New Jersey?: *
If yes, Where is your EMT certification issued from?: *
What is your EMT Identification Number?: *
If yes, What is your EMT Certification Expiration Date:
How long have you been certified as an EMT?: *

Please enter any other certification you have:
Are you currently or have you ever been a member of any other First Aid Squad or similar organization?: *
If yes, please list all organization in detail. Please include the Organization Name, Contact Person, and Phone number.
Please list all responsiblites you have/had as a part of each organization.
Please list your reason for leaving each organization:

List your present or most recent employer.

Employer Name: *
Employer Address (Street, City, Zip): *
Employer Phone: *
-
Employer Contact: *
Job Responsibilities: *
Reason for leaving: *

Reference 1:

Reference Name (1): *
Reference Address (Street, City, State, Zip) (1): *
Reference Phone Number (1): *
-
Reference Years Known (1): *

Reference 2:

Reference Name (2): *
Reference Address (Street, City, State, Zip) (2): *
Reference Phone Number (2): *
-
Reference Years Known (2): *

Reference 3:

Reference Name (3): *
Reference Address (Street, City, State, Zip) (3): *
Reference Phone Number (3): *
-
Reference Years Known (3): *

In the event of an emergency, who would you like us to contact?

Emergency Contact Name: *
Emergency Contact Address (Street, City, State, Zip): *
Emergency Contact Phone 1:
-
Emergency Contact phone 2:
-

 
2017
CALL STATISTICS
JANUARY  103
FEBRUARY  53 
MARCH  91 
APRIL  92 
MAY  88 
JUNE  84 
JULY  78 
AUGUST  87 
SEPTEMBER  89 
OCTOBER  88 
NOVEMBER   
DECEMBER   
YTD  853

 

2016
CALL STATISTICS
JANUARY  61
FEBRUARY  70 
MARCH  74 
APRIL  71 
MAY  78 
JUNE  74 
JULY  101 
AUGUST  73 
SEPTEMBER  71 
OCTOBER  99 
NOVEMBER  77 
DECEMBER  89 
YTD  938

 

 

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