Nutley Volunteer Emergency & Rescue Services, Inc.

Application for Membership

Name (Last, First, Middle)

Home Address

Home Phone

Business Phone

Cell Phone

Email address

Employers Name and Address

Date of Birth (YYYY/MM/DD)

Hair Color

Eye Color

Sex

Male
Female

Marital Status

Number of Children (and ages)

Resident of Nutley?

Yes
No

How many years at present residence?

Previous Address

Drivers License State and Number

Previous Emergency Care/Resue Training and or Experience

Why do you want to join N.V.E.R.S.

How did you hear about N.V.E.R.S.

Indicate the Day of the Week you are avaiable to ride

Have you ever been arrested?

Yes
No

Have you ever been found guilty or pled guilty for any arrests?

Yes
No

If you answered "Yes" to any of the previous two questions, explain any charges, when, and where, in this box

By checking the following box, I agree to abide by the Constitution and the By-Laws of the Nutley Volunteer Emergency and Rescue Squad, Inc. To the best of my knowledge the foregoing answers are true and I understand that any false statements on this application are cause for rejection or dismissal.

I agree

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Nutley Volunteer Emergency & Rescue Services, Inc.

Application for Membership

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