P.O. Box 5314
341 East Orvis Street
Massena, New York 13662
Phone – 315-764-1744
For Billing Call Town Hall 315-769-7109 or
Professional Ambulance Billing 1-888-897-4893
Fax – 315-769-7403
Regular MemberAssociate Member
Home Agency (if applying as an Associate Member)
How long have you resided at the above address?*
How long have you resided in New York State?*
Are you 18 years of age or older?*
If NO, state your age:
Is additional information about a change in your name or your use of an assumed name or nickname necessary to enable a check on your eligibility for membership?*
If YES, explain:
Are you currently employed?*
If YES, please provide employer information below. May we contact your employer as a reference?
Name of Company
Do you have a New York State driver's license?*
Driver's License Number
Please indicate your availability to participate in normally scheduled rescue squad activities (meetings, drills, and emergency calls).
Previous emergency services experience: (include only fire, rescue, police, and emergency medical service agencies)
Name of Agency
Have you ever been a member of the United States Armed Forces?*
If YES, did you receive an honorable discharge?
If NO to the previous question, indicate discharge type:
If you answered YES to being a member of the Armed Forces, please provide details in the space provided below (include service branch and service dates).
Have you ever been convicted or plead guilty to a felony, misdemeanor, insurance fraud, arson, or a reduction of one of these offenses?*
If YES, please give details in the space below.
Please list three personal references, other than members of this organization, who have known you for at least three years.
Reference 1 Name*
Reference 1 Telephone *
Reference 1 Address*
Reference 2 Name*
Reference 2 Telephone*
Reference 2 Address*
Reference 3 Name*
Reference 3 Telephone*
Reference 3 Address *
Please list the names of any acquaintances that are members of this organization.
Our By-Laws require that you pass a physical examination and drug test before becoming a member. The department's designated physician will provide you with a free medical examination. Will you be willing to undergo a medical examination and drug test?*
Will you be willing to undergo random drug screenings once you become a member?*