Applications - Putnam Valley Volunteer Ambulance Corps

2025 EMS Responses
Jan.	59
Feb.	48
March	44
April	61
May
June
July
Aug.
Sept.
Oct.
Nov
Dec
Total	212

Past Call Stats
2024	811
2023	788
2022	1035
2021	854
2020	699
2019	765
2018	774
2017	653
2016	566
2015	565
2014	569
2013	N/A
2012	707
2011	676
2010	686

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Members Area

Applications

Indicates Required Field


What would you like to join as?

Application Type:		Riding Member Associate Member

Personal Information

First Name:
Last Name:
Date of Birth:
Address:
Home Phone:
Work Phone:
Cell Phone:
Email:
Additional Email:

Emergency Contact Information

Name:
Phone :
Relation:

Employer Information

Name of Company:
Name of Supervisor:
Phone Number:
Work Address:

Related Experience

Do you have any related experience in the emergency services or health care field? If so please list:

Do you have your NYS EMT/CFR certifications, CPR or First Aid?

NYS Certifications:		EMT CFR
NYS #:
Exp:
Other Certifications:		CPR First Aid
CPR Exp:
First Aid Exp:

Medical Information

Are you presently under a physician's care for, taking any medications for, or do you have any physical condition that would impair your operation of an emergency vehicle, your use of electronic equipment or your vision, hearing, or ability to lift?:
Have you been arrested for and/or convicted of any crime(s)?:		Yes No

Please list 3 non-personal character references who can be contacted

Ref 1 Name:
Ref 1 Address:
Ref 1 Phone Number:
Ref 1 Relation:
Ref 2 Name:
Ref 2 Address:
Ref 2 Phone Number:
Ref 2 Relation:
Ref 3 Name:
Ref 3 Address:
Ref 3 Phone Number:
Ref 3 Relation:
Are you a member or have you ever been a member of any other Fire Department or Ambulance Corps?:		Yes No
Agency Name:
Agency Address:
Agency Phone Number:
Commanding Officer's Name and Title:
Are you acquainted with any present or past member of the Putnam Valley Volunteer Ambulance Corps and if so who? :
By submitting below the applicant certifies that this information is factual to the best of his/her knowledge. Information on this form will be considered confidential and will not be divulged to any one outside the Corps. However the Corps reserves the right to verify the information provided and to contact the references supplied by the applicant. If there is any condition or issue in the experience of the applicant that might adversely affect this application, the applicant should note that on this application and/or discuss it with the membership committee contact. Meeting are held once the Membership Committee has gone through the process of reviewing your application and you will be advised when to come and be officially interviewed.

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www.FirehouseSolutions.com	Putnam Valley Volunteer Ambulance Corps P.O. Box 141 Putnam Valley, NY 10579	Emergency Dial 911 Office: 845-526-3119 Fax: 845-526-6561