Volunteer Application Form

TVAC is always welcoming new volunteers. Read about the qualifications on our Volunteer page, and fill out the form below. You can also download a PDF version of the application (on the Volunteer page).

You will be contacted via email or phone within a few weeks following our monthly meeting. Any questions, leave a message at (845) 351-4400 or email Glen at tvacapply@yahoo.com. Thank you for your interest!

Basic Information

First Name * M.I. Last Name * Date of Birth *
(MM/DD/YYYY) Social Security Number *
(XXX-XX-XXXX)
Driver’s License Number * Issued in * Sex * Email Address*

Mobile Phone* Alternate Phone

Current Address

Street Address *
City * State * Zip Code *

Previous Address

Street Address
City State Zip Code

Work History

Current Occupation

Have you ever applied/been a member at any ambulance corps? Yes:

Name Street Address City State Zip Code

Riding Member Applicants Only

Do you have a valid CPR-D card? Yes:

Exp. Date (MM/DD/YYYY)

Do you have a valid NYS EMT? Yes:

Certification Number Issued in Exp. Date

Background Check

Have you ever been convicted of a crime (felony or misdemeanor)? * Yes:

Name of Crime Date (MM/DD/YYYY)
Additional Information

Have you ever been convicted of a vehicular moving violation? * Yes:

Name of Violation Date (MM/DD/YYYY)
Additional Information

Character References

Reference 1

First Name Last Name
City State Relationship
Email Phone

Reference 2

First Name Last Name
City Sta te Relationship
Email Phone

Availability

Please check the days you are available below:

Monday Tuesday Wednesday Thursday

Friday Saturday Sunday

Notes about your availabilty:

Terms & Conditions

I agree to abide by the provisions in The Charter, By-Laws, and Standard Operating Guidelines set forth by the Tuxedo Volunteer Ambulance Corps, Inc. * I certify that all above information is true and accurate to the best of my knowledge. *

Disclosure & Release

In connection with my application for membership to the Tuxedo Volunteer Ambulance Corps, Inc., I understand that consumer reports, which may contain public record information, may be requested and obtained. These reports may include information related to my previous driving record, including court actions, citations, license suspensions and revocations.

I have the right to obtain information as to the name, address, and phone number of any agency providing such information and further, may request of that agency, upon proper identification, the nature and substance of all information in its files on me at the time of my request, including all sources of information as well as the recipients of any reports on me which that agency has previously furnished within two (2) years prior to my request.

The authorization shall remain on file and shall serve as an ongoing authorization for the organization to procure motor vehicle reports or other necessary reports at any time during my membership.

I authorize, without reservation, any party or agency contacted to furnish the above-mentioned information. *

Verification

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Be Prepared!