Join Our Team

Applicant Information

Full Name*

First Middle Last

Street Address*

Street Address City State ZIP Code

How long have you resided at this address (years/months):*

Date of Birth*

Month

Day

Year

Age*

Home Phone:*

Cell Phone:*

Email*

Applying for:*

Driving Information

Are you currently a licensed driver in the State of New Jersey?*

Yes

Drivers License Number

License Expiration Date

Month

Day

Year

Do you hold a valid driver’s license from any other state?*

Yes

Other State License Number

Other State License Expiration Date

Month

Day

Year

Endorsements on your license(s)

CDL

Bus

Other (explain below)

Please explain "other" endorsements

How long have you been driving? (years)*

Types/Sizes of Vehicles driven

Any moving violations in the past three years?*

Yes

Any DUI offenses?*

Yes

If yes, when?

Any accidents in the past three years?*

Yes

How many points are currently on your license?

Has your license ever been suspended or revoked?*

Yes

Please explain why your license has been suspended or revoked:

Medical / Health Information

Do you wear any of the following correctional devices?

Eye Glasses

Contact Lenses

Hearing Aids

Other

Do you have any medical or physical conditions that might limit your ability to perform your duties?*

Yes

Please explain those conditions

Biographical Information

Hobbies and Special Interests

Name other organizations to which you belong

How did you find out about the Holmdel First Aid Squad?

Explain why you want to become a member of the Squad

What are your expectations?

Are you related to any member of the Squad?*

Yes

Who are you related to?

Have you previously been accepted to any other First Aid Squad, Fire Company or similar organization(s)?*

Yes

Name of organization

Address of organization

Contact Person

What were your duties and responsibilities?

Reason for leaving (if applicable)

Dates of service (if applicable)

Please list all relevant certifications (CPR, EMT, First Aid, etc.)

Availability

In general, when would you be available to volunteer your time? (check all that apply)*

NOTE: Full members commit to 12 hours/week duty times. Limited members commit to at least 6 hours/week duty times. Duty times are defined as a fixed period during each week when you must respond at first tone out.

Weekday Mornings

Weekday Afternoons

Weekend Mornings

Weekend Afternoons

Monday Nights (7pm to 6am)

Tuesday Nights (7pm to 6am)

Wednesday Nights (7pm to 6am)

Thursday Nights (7pm to 6am)

Friday Nights (7pm to 6am)

Sunday Nights (7pm to 6am)

Is there any reason you may not be able to commit to the hours?

Background Information

Have you ever been convicted of a criminal offense, or have any criminal cases pending against you?*

Yes

If yes, when and what?

Were you ever subpoenaed or ordered to appear in court?*

Yes

If yes, when and what?

Have you ever failed a drug test?*

Yes

If yes, when and what?

Education

Are you currently a full-time student?*

Yes

Where?

Major

Proposed Graduation Date

Month

Day

Year

Highest Degree Achieved

Employment

Are you currently employed?*

Yes

Employment Status

Employer

Employer Address

Street Address City State ZIP Code

Contact Person at Employer

Contact Phone at Employer

References

Reference 1 Name

First Last

Reference 1 Address

Street Address City State ZIP Code

Reference 1 Phone

Nature and length of contact

Reference 2 Name

First Last

Reference 2 Address

Street Address City State ZIP Code

Reference 2 Phone

Nature and length of contact

Reference 3 Name

First Last

Reference 3 Address

Street Address City State ZIP Code

Reference 3 Phone

Nature and length of contact

Emergency Contact

Emergency Contact Name

First Last

Emergency Contact Relationship

Emergency Contact Address

Street Address City State ZIP Code

Emergency Contact Home Phone

Emergency Contact Cell Phone

Emergency Contact Email

Agreement

Consent

I agree to let a representative of the Holmdel First Aid Squad, Inc. conduct an investigative report regarding any and all statements given on this application and I further agree to submit to a physical examination. I agree to be responsible for all and any equipment issued to me, and will return the equipment to the Squad in the same condition in which it was given to me.

Consent

The answers to the foregoing are in my own handwriting and are true to the best of my knowledge and belief. It is understood that any false statements on this application are sufficient cause for rejection or dismissal.

Consent

If acceptance is obtained under this application, I agree to comply with all orders, rules, and regulations (SOGs) of the Holmdel First Aid Squad and the Township of Holmdel. I understand that as part of my membership to the Holmdel First Aid Squad I will be required to be available to ride the minimum number of hours required for membership in the Squad per month, attend mandatory meetings, trainings and drills. Failure to do so may result in my dismissal from the Squad.

Signature of Applicant*

Date*

Month

Day

Year

Membership Application

Applicant Information

Driving Information

Medical / Health Information

Biographical Information

Availability

Background Information

Education

Employment

References

Emergency Contact

Agreement

Crawford Station

Mailing Address

Phone Numbers

Join Our Team

Membership Application

Applicant Information

Driving Information

Medical / Health Information

Biographical Information

Availability

Background Information

Education

Employment

References

Emergency Contact

Agreement

Footer

Crawford Station

Mailing Address

Phone Numbers