MEMS: Reference Form

Reference Form

To assist us in determining this applicant's eligibility for membership, we would appreciate you completing this questionnaire and returning it at your earliest convenience. Please do not share your responses with the applicant. Your responses will be held in strict confidence.

Applicant's Name:

1. How long, and in what capacity, have you known this applicant?

2. How would you rate this applicant's dependability?

3. How would you evaluate this applicant's initiative?

4. Please comment on this applicant's integrity, honesty, and ability to maintain the confidential nature of our business.

5. In your opinion, is this applicant able to perform under stressful situations? Please provide an example.

6. To your knowledge, has this applicant been involved in any activities which demonstrate concern for others? Please describe.

7. Please comment on the general health of the applicant, keeping in mind that our volunteers are required to lift and carry stretchers, ascend and descend stairs while carrying equipment, maintain precarious positions during extrications, etc.

8. Can you offer any further insights regarding this applicant's qualifications to become a member of the Morristown Ambulance Squad, Inc.?

Your Name:

Address:

City, State, & Zip

Phone:

E-Mail Address:

Relationship to Applicant:

Years Known:

Today's Date:

By typing AGREE below and by electronic submission of this reference form I certify that all the statements and information on this form are accurate and complete and that this form was indeed completed by the person named above.

Type AGREE