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275 Montauk Hwy, East Moriches, NY 11940

631-878-4230

president@emcambulance.org

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- Junior Application

Home
Account
- Login
- Logout
Events
About Us
Online Trainings
Links
Member Area
Juniors
- Junior Application

Recruitment

If you are interested in joining East Moriches Community Ambulance, please fill out the form below. Someone will be in contact with you shortly.

Step 1 of 4

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Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Date of Birth*
Social Security Number*
Email*
Do you have a valid driver's license?*
- Yes
- No
Medical Background*
- CPR
- EMT-B
- EMT-CC
- Paramedic
- LPN
- RN
- Doctor
- Other
Select all that apply.
Other Medical Certifications*
If you answered 'other' in the previous message, list them here.
Organizations To Which You Currently or Have Belonged*
Phone*
Occupation*

Past Medical History*
Blood Type*
Hepatitis Vaccine*
- Yes
- No
- Unsure
Allergies*
What time of the day are you generally available?*
- Days
- Nights
Nights Available*
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
A member requires one eight hour duty shift between 2100-0500 hours (9pm-5am).
Is there any information that you think this organization should be made aware of in reference to your application to become a member of this ambulance company?*
Have you ever been arrested (whether or not convicted)?*
- Yes
- No
State reason why and outcome*
Have you ever been convicted of a felony or misdemeanor?*
- Yes
- No
State reason why and outcome*

Have You Ever Been in The Military?*
Are you Currently Discharged from the Military?*
Date of Entry*
Branch of Service*
Date of Discharge*
Type of Discharge*
Explanation of Discharge if anything other than Honorable
Present Military Status*

In order for you to become a member of East Moriches Ambulance, you are going to have to sign a background check release form. Please download it, print it, and fill it out when you come down for your interview. Background Release Form The Board of Directors also require that you fill out the Life Insurance Form for their records, which you can find here: Life Insurance Form
Are you able to upload your certifications?*
Certification Uploads*
Drop files here or
Life Insurance Policy Upload*
Accepted file types: pdf.
You MUST fill out this form prior to submitting your application. The form is a PDF file that you can fill out online. If you have issues filling out the PDF, answer the next question with "YES".
Life Insurance Application Right click and click "Open in New Tab"
Are you having issues uploading the Life Insurance Policy?*
Background Authorization Form*
Accepted file types: pdf.
You MUST fill out this form prior to submitting your application. The form is a PDF file that you can fill out online. If you have issues filling out the PDF, answer the next question with "YES"
Background Release Form Right click and click "Open in New Tab"
Are you having issues uploading the Background Authorization Form?*

Username or Email Address

Password

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Contact Us Emergency: 911
Main: 631-878-4230
Fax: 631-878- 8337

District: president@emcambulance.org

Operations: 54730@emcambulance.org

Additional Information

Physical Address: 275 Montauk Hwy, East Moriches NY 11940

Mailing Address: P.O. Box 295

East Moriches

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