Hatzulas Nefashos Emergency Medical Services

Personal Information

First Name *

Last Name *

Date of birth * +

Driver license # *

State *

Address 1 *

Address 2

City *

State *

Zip Code *

Marital Status *

Number of years married *

Number of kids *

Work Phone *

Home Phone *

Cell Phone *

Email Address *

Position Applying For *

Member

Dispatcher

Service Member

Are you legally authorized to work in the United States? *

Yes

Have you ever been convicted of a felony? *

Yes

If yes, please explain.

Availability

Address Available at *

Shift preference: *

Days

Swing (3pm-midnight)

Night (12-9am)

Other Other

Employment / Yeshivah / Shul

Employer

Company Name *

Start Date * +

Address *

Phone *

Position *

Contact name *

May we contact? *

Yes

Phone Number *

Yeshivah

Yeshivah Ketana *

Yeshivah Gedolah *

Beis Medrash *

College *

Shul

Shul Name *

Rabbi *

Address *

References

Reference 1

Name *

Title *

Email Address *

Phone *

Reference 2

Name

Title

Email Address

Phone

Skills

Medical Experience *

List any additional skills that you would like to mention.

Signature

I certify that all information provided on my application for membership in Hatzulas Nefashos Emergency Medical Services is correct.

I agree to allow Hatzulas Nefashos Emergency Medical Services to check my driving and criminal records prior to hire and to monitor it periodically thereafter. I further agree to report to my supervisor immediately any license suspensions, serious accidents or offenses, or any other condition that may affect my ability to drive a vehicle.

In return for being given the right to make use of the emergency equipment provided by the organization, I obligate myself not to join any other emergency medical orgnization in the Lakewood area for a period of 1 year.

clear

Date * +

Please upload a copy of your EMT Card *

Please upload a copy of your Driver Licence *

Please upload a copy of your Vehicle Registration *

Please upload a copy of your Insurance *