HIGHLANDS FIRST AID SQUAD * difference within their community. No experience is necessary and free training will be provided to you.

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1 :: * I. - HIGHLANDS FIRST AID SQUAD * Valley Street Highlands NJ highlands lstaid@comcast.net Dear Volunteer, The Highlands volunteer First Aid. Squad is seeking new members who are interested in making a difference within their community. No experience is necessary and free training will be provided to you. You will learn skills that may one day save the life of a friend, a neighbor or a loved one. The Highlands First Aid Squad is an all-volunteer organization which provides our community; a 24/7 operation providing quality emergency medical service. Our squad is not only requested for medical services but all fire calls as well. We also respond to borough functions to provide stand-by coverage in the event of an emergency. Please complete the application below. Once the application is complete a background check will be completed. After the background check has been completed you will be contacted by a squad member regarding the status of your application. We look forward to working with you.. One of the greatest services a citizen can render to his/her community is the preservation of life as well as peace of mind. Your service will be sure to reward you with pride and personal satisfaction. Sincerely, Highlands First Aid Squad

2 READ CAREFULLY PRIOR TO FILLING OUT APPLICATION INSTRUCTIONS: Read every question carefully. Answer every question, leave no blank spaces. If a question does not apply to you, use "not applicable" or "N/A". An applicant may be rejected who has intentionally made a false statement of a material fact, and/or practiced, or attempted to practice any deception or fraud in this application. The applicant shall personally prepare this form. All entries, except in the signatures must be hand written in black ink. If the space provided for answering any question is insufficient, attach a separate sheet of paper and include the question and question number above the answer or continuation. RELEASE AUTHORIZATION To all courts, Probation Departments, Selective Service Boards, Physicians, Hospitals, Employers, Educational and other institutions and Agencies without exception: I,, am making application to the Borough of Highlands volunteer First Aid Squad. As a result, an investigation is being conducted to determine my eligibility for membership/employment. Therefore, you are authorized to release to the Borough of Highlands First Aid or its representative, any and all information documentary or otherwise pertaining to the above applicant that they may request. I hereby release, discharge, and exonerate the Borough of Highlands First Aid, its agents or representatives and any person so furnishing information, from any liability of every nature and kind arising out of the furnishing, inspection, or collection of such documents, records, and other information or the investigation made by the Borough of Highlands First Aid. A photo static copy of this authorization will be considered as effective and valid as the original. Signature: Date:

3 PERSONAL DATA Cadet Application D Regular Member D Attach photo Last Name First Name MI Address City ST Zip Address Home Phone Cell Phone Date of Birth Current Age SSN Driver's License Number State issued Expiration Date 6. How long have you lived at the above address? a. If you have not lived here during the past ten years, please provide the address(s) at to where you have previously resided, including dates.

4 7. Do you previously or currently hold a driver's license from ANY other state? a. If so, please provide the state and the driver's license number, if known. \ REFERENCES 8. Give three references (not relatives) who have known you well during the past FIVE years. DO NOT include first aid members of the Borough of Highlands First Aid Squad. A. Complete Name: B. Complete Name: c. Complete Name: Years Acquainted: Years Acquainted: Years Acquainted: 9. List the names of first aid members within New Jersey with whom you are personally acquainted: D. Complete Name: Department: Years Acquainted: E. Complete Name: Department: Years Acquainted: F. Complete Name: Deprurnnent: Years Acquainted:

5 EDUCATION 10. List chronelogically (earliest dates first) all schools, colleges, and training courses you have attended: School Exact Address Dates #of Years Type of Graduated? From-To Attended Degree Yes or No MILITARY SERVICE 11. Have you ever served in an active military organization of the United States? A. Branch of service: B. What was the condition of your discharge/separations? C. How many discharges/separations from the service were you given? D. Were you ever court martialed, tried on charges or were you the subject of a summary court, deck court, Captain's mast, company punishment, office hours or any other disciplinary action?. Number of occurrences: Please give details of charges, agency concerned, dates, dispositions, location, and name of military base:

6 EMPLOYMENT 12. Present Employer: \ Phone: Immediate Supervisor: Date Hired: Describe Job Duties: Were you ever discharged or asked to resign from employment? If yes, give an explanation and details of discharge or forced resignation below including the name of the business: 14. Were you ever subjected to disciplinary action in connection with any employment? If yes, explain where and when: VOLUNTEER 15. Have you ever been a cadet or regular member of ANY police, fire or first aid organization? DYes 0No. If yes, which organization, when and where? Have you ever been terminated, rejected, and/or asked to resign or have been suspended from any of the above? 0 Yes []No. If yes, which organization, whed: and where?

7 ARRESTS, SUMMONSES, ETC 17. Have you ever been arrested, indicted or convicted for ANY vi<?lation of the law in ANY state? City/ST: Dme: Ch~ge: Disposition: City/ST: Dme: ChMge: Disposition: MOTOR VEHICLE HISTORY 18. Have you ever received a summons or a violation of the Motor Vehicle Laws in this state or any other state? (Do not include parking violations) If yes, complete the following: Date Offense Location Court Your Age Police Agency Disposition (at time) 19. Was your Motor Vehicle Registration certificate, drivers, or other vehicle operator's license ever revoked or suspended in this state or any other state? If yes, which license? Date: Location: Reason: Date of restoration: