STONY BROOK VOLUNTEER AMBULANCE CORPS, INC.
Serving Stony Brook University Community
Since 1970
Thank you very much for your interest in joining the Stony Brook Volunteer
Ambulance Corps for the Fall of 2014!
We are the primary emergency ambulance service for the Stony Brook University and
surrounding areas. We operate twenty-four hours a day and seven days a week. We hold our
volunteers to the highest standards and appreciate the endless time and effort they give to help
others in their community.
In order to become a probationary member, all prospective members must follow the process
listed below:
 You must fill out this application and submit it, along with a copy of your class
schedule, to your first-round interviewers
 Fill out an online application found on our website www.SBVAC.org
 Email your resume to SBVACapplications@gmail.com, it is also recommended a
reference submit a letter of recommendation with subject line RE:YOURNAME
 Should you pass the first round, you must attend a second round interview
 You must provide proper proof of certification, if any
 You must adhere to the guidelines and requirements listed (page 5)
Please fill out this application entirely and bring it with you to your interview. This information
will only be used for membership purposes, and will not be disclosed without the permission of
the applicant.
If you have any questions, please feel free to contact the President at president@sbvac.org.
Good luck!
Jessica Liebman
President
Stony Brook Volunteer Ambulance Corps
Joseph Lalor
Training Officer
Stony Brook Volunteer Ambulance Corps
4780 SUNY • STONY BROOK, NY • 11794-4780
PHONE: 631-632-6737
EMAIL:OFFICE@SBVAC.ORG
FAX: 631-632-4108
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Part I: Applicant Information
All information must be filled out to the best of your knowledge. Any falsification will
lead to immediate rejection, or dismissal if found at a later date.
Last Name
Home Address
First Name
City
Middle
Age
State
Zip
Date of Birth
Cell Phone
E-mail Address
Emergency Contact Information:
Name
Phone Number
Relationship
Please answer the following questions:
Do you live on campus?
 Yes, I live in ______________ (list dormitory)
 No, I commute from home
 No, I commute from ___________ (list city)
How many more years do you expect to be attending Stony Brook University: ________
Have you previously applied to SBVAC?
 Yes, during ______________ (list semester and year)
 No
Are you a United States Citizen?
 Yes
 No
Have you ever been convicted of a felony, misdemeanor or similar conviction?
 Yes
 No
If yes, please explain: _________________________________________________________
___________________________________________________________________________
Has your driver’s license ever been suspended/revoked?
 Yes
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 No
If yes, please provide reason and state of suspension or revocation: _____________________
___________________________________________________________________________
Part II: Past Employment Information
All information must be filled out to the best of your knowledge. Any falsification will
lead to immediate rejection, or dismissal if found at a later date.
Past Work or Volunteer
Experience
Current Certifications
Please check all that apply:
Dates
Brief Description of
Responsibilities
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ID Number
Expiration Date
First Aid or CPR
Certified 1st Responder
NYS EMT
NYS EMT-I
NYS EMT-CC
NYS EMT-P
NREMT
NREMT-I/P
Drivers License
Part III: Short Essay
All information must be filled out to the best of your knowledge. Any falsification will
lead to immediate rejection, or dismissal if found at a later date.
Personal statements are an integral component of our application. They give us an idea of what
applicants are like, provide an opportunity for you to bring pertinent information to our attention,
and are a significant factor in our admissions process. Please answer the following in 300 words
or less (about ½ a typed page, single spaced) in the spaces provided below. A comments section
has also been included if you would like to provide any additional information that has not
already been expressed within this application.
In 300 words or less, please describe your interest in SBVAC and EMS. Why are you applying
and what do you hope to get out of the experience?
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Please use the space below to provide any additional comments you may like to add:
______________________________________________________________________________
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Part IV: Requirements and Acknowledgements
All information must be filled out to the best of your knowledge. Any falsification will
lead to immediate rejection, or dismissal if found at a later date.
All members of the Stony Brook Volunteer Corps are required to adhere to certain conditions as
described by the New York State Department of Health. These requirements allow our agency to
ascertain that all of our members are of good physical condition, as well as sound mind and
reason.
A probationary member MUST:
 Be 18 years of age or older (if younger, must provide written parental permission)
 Be capable of performing the physical tasks of an EMT including but not limited
to lifting at least 120lbs unassisted and 250lbs assisted
 Be in good physical health and able to bend, stoop, and crawl on uneven terrain,
able to work in low light, confined spaces, am unaffected by loud noises and
flashing lights
 Be capable of reading, writing, and speaking English
 Not have convictions, or be under any charges
 Possess the emotional stability and maturity to perform tasks professionally in a
high stress environment
Other probationary member responsibilities and academic responsibilities for probationary class
will be outlined in a semesterly contract.
I, ___________________, acknowledge that all information supplied in this application is true
and current. I also acknowledge that I can fulfill all duties required of me as a probationary
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member, including those requirements outlined by the New York State Department of Health, as
well as those listed in this application.
____________________________
Signature
__________________
Date