Join Our Team & Membership Application

2. Date of Application
   Date of Application
3. Sponsoring Active Member of RAA
5. Full Name*
6. Social Security Number*
8. Street Address*
9. Date of Birth
   Date of Birth
11. Town*
12. State*
13. Zip Code*
15. Home Phone Number
16. Mobile Phone Number
18. Occupation
19. Employer
21. CT EMT Number
22. Level
23. Expiration Date
    Expiration Date
25. Other EMS Training

    1. Blood Bourne
    2. HazMat
    3. Mass Casualty
    4. Aspirin
    5. 12 Lead
    6. Other
27. Driver's License Number
28. Driver's License State
29. CEVO Training

    1. Yes
    2. No
31. Car Make & Model
32. Color
33. Registration Number
37. I have never been found guilty, or plead guilty or no contest, to a criminal charge

    1. True
    2. False
39. If false please explain the charge (date, nature, place, etc.)
41. No civil lawsuit alleging actual or attempted sexual discrimination, harassment, exploitation, or misconduct, physical abuse, or financial misconduct has ever resulted in a judgment being entered against me, been settled out of court, or been dismissed because the statue of limitations has expired or due to a defect in pleadings.

    1. True
    2. False
43. If false please explain the charge (date, nature, place, etc.)
45. I have never terminated my employment, professional credentials, or service in a volunteer position or had my employment, professional credentials, or authorization to hold a volunteer position terminated for reasons relating to allegations of actual or attempted sexual discrimination, harassment, exploitation, or misconduct, physical abuse, child abuse, or financial misconduct.

    1. True
    2. False
47. If false, please give a short explanation (dates, name of employer, volunteer supervisor, nature of dismissal)
49. With respect to my driving record, I have not had my license suspended or revoked within the last five (5) years due to reckless driving or driving while intoxicated and/or under the influence of a controlled substance.

    1. True
    2. False
51. If false, give a brief explanation
53. Is there any fact or circumstance involving you or your background that would call into question your being entrusted with the responsibilities for which you are applying?

    1. Yes
    2. No
55. If yes, please give a brief explanation
57. Do you have physical limitations which would prevent you from carrying out your duties as an EMT?

    1. Yes
    2. No
59. If yes, please explain:
61. Please list two reference other than family who can attest to your character and/or ability:

    Please include, Name, Contact Phone Number and how you are acquainted with this person.

63. Reference #1
64. Reference #2
66. RAA reserves the right to conduct a background check for all applicants. All equipment provided by the Association remains the property of the Roxbury Ambulance Association and must be returned upon leaving membership in the Association.
68. Signature
69. Date
    Date
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit

* indicates a required field