Date: Incident



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APPLICATION FOR MEMBERSHIP

Name:         Date of Birth:     / /   Age:      

Address:         City:        State:       Zip:      

SS#:        Phone #:       E-mail:       

Drivers License:        State:       

Do you have any current points or restrictions on your license? YES NO

If yes, please explain:        

In case of emergency, please notify:     Phone #:      

[pic]Employer:         Address:        

Phone #:       Occupation:        

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Any medical conditions or physical handicaps? YES NO If yes, explain in the space below:

       

       

Emergency Medical Information: Do you presently have any allergies or do you take medications at this time? YES NO

If yes, please record the appropriate information:        

       

Have you ever worked for an ambulance service before? YES NO If yes, please specify name of squad, address and senior officer:        

       

What is your reason for seeking membership with Deerfield Valley Rescue, Inc.?        

       

At this time, I am currently certified as: None 1st Responder EMT Other:         State:      

Which level(s) of certification do you plan to pursue? Please check all that apply

1st Responder EMT-Basic EMT-Intermediate Paramedic CPR Instructor

None Presently Other:       

IN THE SPACE BELOW, PLEASE LIST ALL PREVIOUS TRAINING

TRAINING COURSE/LOCATION DATE COMPLETED EXPIRATION DATE

       

       

       

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The following information is needed for DVR’s purposes as well as the State of Vermont, as it relates to the possible issuing of licenses when training courses are completed. All members are required to be in compliance of all requirements set forth by DVR and the State of Vermont. Applicable statutes and/or rules are listed with each compliance item.

Child Support (15 V.S.A. 795)

A license may not be issued or renewed unless the applicant certifies that he/she is not under and obligation to pay child support or is in good standing with respect to or in full compliance with a plan to pay any and all child support payable under a support order as of the date the application is filed. A “license” is any license, certification, or registration issued by any agency to conduct a trade or business, including a license to practice a profession or occupation. “Good Standing” means that less then one-twelfth of the annual support or obligation is overdue; or liability for any support payable is being contested in a judicial or quasi-judicial proceeding; or the applicant is in compliance with a repayment plan approved by the office of child support or agrees to by the parties. The licensing agency may also find that requiring immediate payment of child support due and payable would impose an unreasonable hardship.

Tax Liability (32 V.S.A. Section 3113)

No state agency may renew any license or authority to conduct a trade or business unless the applicant first verifies in writing that he or she is in good standing with respect to or in full compliance with a plan to pay any and all taxes due as of the date such statement is made. “Good Standing” means that no taxes are due and payable; or the liability for any taxes due and payable is on appeal; or the person is in compliance with a payment plan approved by the Commissioner of Taxes. The licensing agency may condition license renewal on terms which would place the applicant in good standing with respect to any and all taxes as soon as possible, if the agency finds an unreasonable hardship.

Please answer the following questions:

Are you currently illegally using drugs or have you recently stopped illegally using drugs? YES NO

If yes, please explain:       

      

Have you ever been convicted of a crime not previously reported to this organization? YES NO

If yes, please explain:       

      

Have you ever had any action taken against any professional license or certification that you have held in Vermont or elsewhere? YES NO

If yes, please explain:       

      

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I have read the above material concerning child support and tax liability. I hereby certify that I am not under an obligation to pay child support or I am in good standing as described above, regarding child support. I hereby further certify that I am in good standing, as described above, with respect or in full compliance with a plan to pay any and all taxes due as of the date of this statement. This certificate is made under the pains and penalties of perjury.

I attest the information contained with in this application is correct and factual. Any intentional misrepresentation may be deemed by the Commissioner of Health and/or the Deerfield Valley Rescue Board of Directors to be in violation of Vermont law, and may subject my certifications to conditions, suspensions, revocation or denial

I hereby wish to be accepted as a volunteer member of Deerfield Valley Rescue, Inc. I also agree to abide by all the Rules/Regulations and Bylaws as set forth by this organization. I grant permission for Deerfield Valley Rescue, Inc. to obtain any and all information with regard to a complete and personal background check as outlined in the accompanying forms.

               

Signature of applicant Date

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DVR USE ONLY Date Initials/Signature

Application submitted                

Background check to WPD/VCIC               

Invited to next meeting               

Accepted into membership               

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