Regular Membership                                  Associate Membership   

Name ___________________________________________________________________________________

Address _________________________________________________________________________________

Phone _______________________________________    Date of Birth _______________________________

Email Address ____________________________________________________________________________

How long at present address? _____________________________    US Citizen?          YES              NO

NYS Driver's License Number ________________________________________________________________

Employer ____________________________________      Marital Status _____________________________

Have you ever been convicted of a felony, misdemeanor, or moving violation?     YES     NO

If Yes, describe:*___________________________________________________________________________

________________________________________________________________________________________

Please list any previous medical training:  _______________________________________________________

________________________________________________________________________________________

                                                                                Character References

                                                      (Please avoid using family members and current squad members)

Name ___________________________________________    Phone ________________________________

Name ___________________________________________    Phone ________________________________

Name ___________________________________________    Phone ________________________________

I hereby authorize the release of any and all information, or copy thereof, to any persons duly accredited by and representing Massena Volunteer Emergency Unit upon request of the bearer.  I also understand that upon approval to MVEU, I will, within 2 years after being voted in for permanent membership, attain the level of Emergency Medical Technician.  If I fail to do so in the alloted time, I will be asked for resignation in accordance with the MVEU By-Laws.  I certify that all of the above statements are true to the best of my knowledge.  I also acknowledge that false statements made by myself may be grounds for dismissal.

Applicant Signature ___________________________________________   Date _______________________

Sponsor Signature  ___________________________________________   Date _______________________