Application

Regular Member Cadet Member Auxiliary Member


Full Name:
Home Address:
Years at this Address:
If less than 5 yrs, how long at previous?
Home Phone:
Cell Phone:
Age (If less than 18):
Date of Birth (if younger than 18):
E Mail Address:


Driver's License No: Have you been involved in an automobile accident or had a moving violation in the last five years? If yes, please explain below..
Current Employer:
How long Employed there?
Employer's Address:
Employer's Phone No:

Are you presently enrolled in high school or college?
If so, please indicate school name, address, your grade level, and expected graduation date on the bottom of this page. If you are a college student, please also list your school address.

Do you have any physical or psychological conditions which would prevent you from or restrict you in the performance of your duties as a South Orange Rescue Squad member as explained in your interview?
If yes, please explain below.

Are you currently under the care of a physician?
If yes, please explain on bottom of this page.

Have you ever been arrested?

Have you ever been convicted of a crime?

If yes to either question, please explain on bottom of page.

Please list any previous medical training you have received: CPR, EMT, First Aid, First Responder, Other (explain)

List any present or previous rescue squad or first aid squad affiliation:

Please list any South Orange Rescue Squad members that you know:

References: Please list two individuals who are not related to you and include their name, address, and telephone number:

Other additional Information: Motor vehicle violations, Education, Medical Restrictions, Physician, etc.

I certify that the foregoing information is true and accurate. I give my permission for the South Orange Rescue Squad to inquire about and verify any information that is contained herein.

I Agree