ll Applications must submit two letters of reference. Letters of reference may not come from relatives or PCVAC members. In addition, applicants must submit a complete medical clearance (the Corps. Physician John A. McGurty, JR M.D. will perform the examination at no charge, or you may choose the option of going to your own physician). You must have the physical before you are interviewed. When you come for the interview, Please bring you physical clearance form. Also bring a copy of CPR card (if you have one).

Please note in accordance with Rules and Regulation, active members are required to pull 3 hours of duty per week at PCVAC hq.

I hereby agree to serve in accorand to the by-laws and Policies of the Peekskill Community Volunteer Ambulance Corps., under the direction of the duly elected or appoionted officers of the organization. I also agree that all Corps keys,portable radios,pagers and/ or other items loaned are to be returned immedientaly on demand. I will consider as confidential, all information which I may hear directly or indirectly, concerning a patient, doctor, or member. I further agree to act in the name of the Corps only as authorized by the officers or directors. If any part of this application is falsified it may be gorunds for removal from PCVAC or denial of membership.

Signature: _________________________________________Date: ____________

The Peekskill Community Volunteer Ambulance Corps. Does not discriminate on the basis of race, religion, sex, age or natioal origin.

                                                              Office Use Only
                                 Action                                                               Date

          Membership Committee Review:                                                 _____________

          General Membership Approval:                                                   _____________

          Probationary Membership Approval:                                            _____________

          Active Membership Approval:                                                     _____________
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