North Greece Fire Department
Application for Membership Form |
|
Name: |
|
Address: |
|
Telephone (Home): |
|
Telephone (Work): |
|
Pager (D or V): |
|
Email Address: |
|
Date of Birth (MM/DD/YYYY): |
|
|
How long have you resided at the above address: |
years:
|
months:
|
How long have you resided in New York State |
years:
|
months:
|
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 nicname necessary to enable a check on your eligibility for membership?
|
If "Yes", explain: |
|
| |
|
|
|
Type of Membership: |
|
|
Are you currently employed? |
|
if "Yes", give employer info: |
May we contact your employer as a reference: |
|
Name of Company: |
|
Company Address: |
|
Company Telephone: |
|
|
Do you have a vald NY State Drivers's License? |
|
Driver's License Class: |
|
|
| Please indicate your availability to participate in normally required fire department activities (meetings, drills, and emergency calls). Please check appropriate time periods: |
| Weekdays: |
Days: |
|
Evenings: |
|
Nights: |
|
| Weekends: |
Days: |
|
Evenings: |
|
Nights: |
|
|
| Previous emergency services experience (include only fire, rescue, police, and emergency medical service agencies): |
Name of Agency: |
|
Contact Person: |
|
Agency Address: |
|
Agency Telephone: |
|
|
| Have you been a member of the US Armed Forces: |
|
| If "Yes", did you receive a dishonorable discharge: |
|
| Dishonorable discharge is not an absolute bar to membership. This and other factors will affect a final membership decision. If the above answer is "Yes", give complete details in the space provided for additional information on the last page (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" give details in space provided for additional info: |
|
|
| Please list the Names of any acquaintances that are members of this organization: |
|
|
| Please list three personal references, other than members of this organization who have known you for at least three years. |
Reference One Name: |
|
Phone: |
|
Address: |
|
Reference Two Name: |
|
Phone: |
|
Address: |
|
Reference Three Name: |
|
Phone: |
|
Address: |
|
|
| OSHA regulations require that you pass a physical examination before becoming an interior structural fire fighter. The department's designated physicians wil provide you with a free medical examination. |
| Will you undergo a medical examination? |
|
|
| ADDITIONAL INFORMATION: |
|
|
 |
|
|
|
|
|
|
|