Qualifications:

Level Expires ID #

AHA CPR……………………………______________ ____________ _____________

Certified First Responder………….______________ ____________ _____________

Emergency Medical Technician….______________ ____________ _____________

Other Revelent……………………_______________ ____________ _____________

Have you been vaccinated for Hepatitis B? Yes No If yes, give dates;

First Shot __________ Second Shot __________ Third Shot ____________ Titer? _________

Past Emergency Service / Medical Providers With Who Afflicated

Name of Organization Location How Long Supervisor

Date of Birth: ________/ _________/ _______

Social Security Number: _______-_______-_______

Drivers License Number: ___________________ State_________ Class______

Moving Violations (Last Three Years)

Date of Violation Infraction Date of Conviction Court

_____/_____/_____ ________________ _____/_____/_____ _______________

_____/_____/_____ ________________ _____/_____/_____ _______________

_____/_____/_____ ________________ _____/_____/_____ _______________

I, ____________________________ give the North Greenbush Ambulance Association, Inc. permission to obtain an abstract of my drivers license record.

______________________________________ _____________________

Signature Date