Katonah Bedford Hills Volunteer Ambulance Corps

Name*

Date of Birth*

Address*

City, State Zip*

Home Phone*

Work Phone

Cell Phone

Cell Phone Carrier

Email*

TShirt Size

Where did you hear about us?

Driver's License ID # *

Name of Employer

Address of Employer

Agency Name/Address

Contact Name

Contact Telephone Number

The Corps asks that you're available to respond for six hours
a week, either day or night; when would you be able to
respond?*

DaysNightsBoth

If you are unable to respond to the Corps within the required
5 minutes, would you be willing to stay at our headquarters
or within close proximity to the Corps during your
shift?*

YesNo

Please explain why you would like to be a member of the
Corps:*

Please list the names, addresses and telephone numbers of
three non-family character references:

Reference 1*

Reference 2*

Reference 3*

Have you ever taken a Defensive Driving course?*

NoYes

If Yes, agency/organization where you took your course and
the date

Has your license ever been suspended or revoked?*

NoYes

If Yes, explain

Permission for arrest check: *

Permission to authorize drivers license checks: *

Please list any accidents over the past 36 months. Note: All
driving records will be verified through insurance companies.

Have you ever been convicted of a felony?*

NoYes

If so, date of offense

Signature*

Date