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Manasquan First Aid Squad, Inc.

-Application for Membership- Please Print All Information

Indicate the classification of membership applying for:

First Aider ____ Junior (under 18) ____ Associate ____ DEMOGRAPHICS Name: _______________________________________________________ Address: _____________________________ Town/State: __________ Date of Birth: _________________________ Age: ______ Sex: _____ Driver’s License #: _____________________________________________ Social Security #: ______________________________________________ Height: _________ Hair Color: ________ Eye Color: _________ Email: _______________________________________________________ Home Phone: ______________________ Cell: _____________________ Cell Service Provider: _________________ Smart Phone? YES or NO Select a 4-digit pin number for building access: ____________ Marital Status: _______________ Name of Spouse: ____________ Children: _____________________________________________________

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ALL APPLICANTS MUST AGREE TO SUBMIT TO A COMPLETE BACKGROUND

CHECK. TO FACILITATE THIS INQUIRY, YOU MUST PROVIDE COMPLETE DRIVER’S LISCENSE INFORMATION, UNDERGO A PHYSICAL EXAM,

AND BE FINGERPRINTED AND PHOTOGRAPHED IN ADDITION TO PROVIDING ALL INFORMATION REQUESTED ON THIS APPLICTION.

PHYSICAL EXAMINATION Physician’s Name (print): ______________________________ Accepted: _____________ Rejected: ____________ If rejected, briefly state reason: __________________________________________________________________________________________________________________________ Physician’s Signature: ___________________ Date: _______________ RECORDS Completed by the Manasquan Police Department, 201 E. Main St. Fingerprinted by: ________________________ Date: _______________ Photographed by: ________________________ Date: _______________ Have you ever been arrested? _____ Have you ever been convicted of a crime? _____ If yes to either, please explain: __________________________________________________________________________________________________________________________ _____________________________________________________________

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EXPERIENCE Do you have any previous first aid experience? _______________________ Any current or past first aid certification and/or training? _______________ Please list type and date of training: _______________________________________________________________________________________________________________________________________________________________________________________ Place of employment: ___________________________________________ Phone #: _______________ Date hired: _________ Date left: ___________ Place of prior employment:_______________________________________ Phone #: _______________ Date hired: _________ Date left: ___________ How long at your present address? _______________ Previous address: ___________________________________________ How many years?: ______________ Previous address: ___________________________________________ How many years?: ______________ What schools and/or colleges have you attended and the years? _______________________________________________________________________________________________________________________________________________________________________________________ -Please tender THREE letters of reference with address and phone number- Applicant’s Signature: ________________________ Date: __________

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COMMITTEE REVIEW

This section for Manasquan First Aid Membership Committee ONLY Fill in dates

Application Received: _________________ Background Check Complete: _______________ Membership Committee Interview: _______________ Members Present: _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ Accepted for Probation: ________________

Comments/Notes: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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