membership

Join The Bellmore-Merrick EMS Team

NO EXPERIENCE NEEDED!

Adult Applicants (18+)

Bellmore – Merrick EMS is a great place for you to fulfill your dream to help people and at the same time learn new skills that can be used in every day life. BMEMS has a friendly membership that is more than willing to assist you in questions you have. Bellmore - Merrick EMS will sponsor members to attend all EMS certification courses with the exception of the EMT-Paramedic course.

Junior Applicants (15-17)

Bellmore – Merrick EMS is always looking to receive Junior Squad applications. Have you ever said to your self in school, “When will I ever use this in real life?” if you have then this is the place for you! The Junior Squad is a great way to get introduced into the emergency medical field, as well as a great way of learning invaluable skills that you can actually use in every day life. While in the Junior Squad you will learn the ins and outs of the everyday operation of the company as well as starting your training to become an Emergency Medical Provider.

Membership Application

PRINT OUT YOUR APPLICATION BY CLICKING THE ICON

Once completed, you can feel free to drop off your membership application personally, at our headquarters. The location of our headquarters can be found on the Contact page. You can also print it out and mail it to us using the respective addresses below.

Junior Squad Applicants please address your application to:
Junior Squad Membership
Bellmore-Merrick EMS
PO Box 8
Bellmore, NY 11710-0008

Adult Applicants please address your application to:
Membership
Bellmore-Merrick EMS
PO Box 8
Bellmore, NY 11710-0008

Bellmore-Merrick Emergency Medical Services Membership Application

Date

Name: Last, First M.I.

Address

N.Y.S. Driver #

Have you ever been convicted of any offence involving any dishonesty or breach of trust (including but ont limited to robbery, embezzlement, forgery, perjury, tax evasion, theft etc.)?

Please provide the required field.

How were you referred to BMEMS?

Please provide the required field.

Reference #1 Name

Address

Home Phone

Work Phone

Reference #2 Name

Address

Home Phone

Work Phone

Sponsoring Member

Date of Birth

Date Available

Home Phone

Work Phone

Shift Preference

Please provide the required field.

Have you ever been a member of any Fire Department or Ambulance Company, either paid or volunteer?

Please provide the required field.

Do you have any condition, illness, disability, either temporary or permanent, which may limit your ability to ride calls on the ambulance?

Please provide the required field.

High School

Major

Graduation Date

College

Major

Graduation Date

Graduate School

Major

Graduation Date

Any other Classes or Education

Name of Employer

Adress (Street, City, State, Zipcode)

Date Hired

Date Terminated

Last Position

Last Department

Name of Supervisor

Reason for Leaving

May we contact your current employer to verify employment?

Please provide the required field.

Name of Employer

Adress (Street, City, State, Zipcode)

Date Hired

Date Terminated

Last Position

Last Department

Name of Supervisor

Reason for Leaving

Have you ever been involuntary discharged or fired?

Please provide the required field.

Do you have any emergency medical training or any existing certifications?

Please provide the required field.

The information provided on the application is accurate to the best of my knowledge and subject to verification by BMEMS. I understand that proof of U.S. citizenship, proof of age, and a photograph may be required for membership. I understand I must truthfully answer all the questions on this application. I understand that if I do not, I may be refused acceptance or separated if i am a current member. I Authorize all previous employers to furnish BMEMS with whatever information they may have regarding my membership and my reason for leaving, and release my prior employers, prior departments, and BMEMS from all liability for any damage resulting from the information provided.

Please provide the required field.