Katonah-Bedford Hills Volunteer Ambulance Corps

KBHVAC ONLINE MEMBERSHIP APPLICATION In order to become a member, you must live or work in the Katonah-Bedford Hills area and arrive at the ambulance corps within 5 minutes of your pager alert. There are multiple places in this application where a signature is required; you will be asked to sign the application during your interview. *All fields must* be completed.**
Name
Date of Birth
Street Address
City/State/ZIP
Home Telephone
Work Telephone
Cell Phone
eMail
Name of Employer
Address of Employer
*Under 18 years of age? (All Junior Corps members must have a parfent or legal guardian sign)*	Yes No
Previous Affiliations: 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?	Days Nights Both
Preferred Day of Week
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?	Yes No
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?	Yes No
If Yes, agency/organization where you took your course and the date
Has your license ever been suspended or revoked?	Yes No
If Yes, explain
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?	Yes No
If so, date of offense








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