APPLICATION FOR MEMBERSHIP TO THE BALDWINSVILLE VOLUNTEER FIRE DEPARTMENT COMPANY INCORPORATED
UPON COMPLETION RETURN TO:
BALDWINSVILLE FIRE DEPARTMENT
ATTENTION: MEMBERSHIP COMMITTEE
7911 Crego Rd.
BALDWINSVILLE, NEW YORK 13027
Baldwinsville Volunteer Fire Department
Company Incorporated
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY. HAVE YOUR SIGNATURE NOTORIZED, WHERE REQUIRED, AND SIGN BEFORE SUBMITTING YOUR APPLICATION
WE WOULD LIKE TO THANK YOU FOR SHOWING INTEREST IN JOINING THE BALDWINSVILLE VOLUNTEER FIRE DEPARTMENT COMPANY INCORPORATED. THE BALDWINSVILLE FIRE DEPARTMENT DOES NOT DISCRIMINATE BECAUSE OF RACE, CREED, COLOR, RELIGION, SEX, OR NATIONAL ORIGIN.
AS PART OF OUR MEMBERSHIP APPLICATION PROCEDURE, A ROUTINE CRIMINAL BACKGROUND CHECK WILL BE MADE WHICH WILL PROVIDE APPLICABLE INFORMATION CONCERNING YOUR CHARACTER, GENERAL REPUTATION AND PERSONAL CHARACTERISTICS. A NEW YORK STATE DEPARTMENT OF CRIMINAL JUSTICE SYSTEMS CHECK, AS REQUIRED BY LAW, WILL ALSO BE MADE FOR ANY ARSON CONVICTIONS. UPON WRITTEN REQUEST, ADDITIONAL INFORMATION AS TO THE NATURE AND SCOPE OF THE REPORT, IF ONE IS MADE, WILL BE PROVIDED.
I UNDERSTAND THAT ANY FALSE ANSWERS OR STATEMENTS OR IMPLICATIONS MADE BY ME ON THIS APPLICATION OR OTHER REQUIRED DOCUMENTS MAY BE CONSIDERED SUFFICIENT CAUSE FOR DENIAL OF MEMBERSHIP. I ALSO UNDERSTAND THAT IF ACCEPTED FOR MEMBERSHIP, ALL EQUIPMENT ISSUED TO ME SHALL REMAIN THE PROPERTY OF THE BALDWINSVILLE FIRE DEPARTMENT AND MUST BE SURRENDERED UPON TERMINATION OF MEMBERSHIP.
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ, AND COMPLETED THIS APPLICATION AND ALL ENTRIES ON IT, AND ALL OF THE INFORMATION IN IT IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
SIGNED: ______DATE: ______
Baldwinsville Volunteer Fire Co, Inc.
P.O. BOX 257
Baldwinsville, New York 13027
MEMBERSHIP APPLICATION
APPLICANT MUST BE 18 YEARS OF AGE AND OUT OF HIGH SCHOOL
FOR FULL MEMBERSHIP – 16 YEARS OF AGE FOR R.A.M.
(RESTRICTED ACTIVE MEMBERSHIP)
PLEASE PRINT OR TYPE
NAME: ______DATE:______
LAST FIRST M.I.
ADDRESS: ______APT#______
CITY: ______ZIP:______HOME PHONE:______
AGE: ______DATE OF BIRTH: ___/___/___ PLACE OF BIRTH:______
SOCIAL SECURITY NUMBER: ______
NYS DRIVER’S LICENSE ID #: ______CLASS(ES):______
(OTHER) STATE:______#:______CLASS(ES):______
HAVE YOU EVER BEEN CONVICTED OF:
1) TRAFFIC VIOLATIONS (EXCLUDING PARKING TICKETS)? ______YES ______NO
2) A CRIME (MISDEAMEANOR OR FELONY)? ______YES ______NO
IF YES, LIST DATE AND TYPE OF CONVICTION: ______
______
(ATTACH ADITIONAL SHEETS IF NEEDED)
EMPLOYMENT
CURRENT EMPLOYER: ______
BUSINESS ADDRESS : ______
SUPERVISOR’S NAME: ______BUS. PHONE: ______
HOW LONG HAVE YOU BEEN EMPLOYED BY THIS FIRM? ______
PREVIOUS EMPLOYER: ______
BUSINESS ADDRESS : ______
SUPERVISOR’S NAME: ______BUS. PHONE:______
HOW LONG WERE YOU EMPLOYED BY THIS FIRM? ______
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MILITARY SERVICE
HAVE YOU EVER SERVED IN THE U.S. ARMED FORCES? ______YES ______NO
BRANCH: ______DATES – FROM______-______
TYPE OF DISCHARGE: ______
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EDUCATION
HIGH SCHOOL: NAME: ______
ADDRESS: ______
ARE YOU STILL IN SCHOOL? ______YES ______NO
HIGHEST GRADE COMPLETED: ______
COLLEGE: NAME: ______
ADDRESS:______COURSE OF STUDY: ______
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FIRE FIGHTING OR EMS EXPERIENCE
HAVE YOU EVER HELD MEMBERSHIP IN THIS DEPARTMENT? _____YES ____NO
IF YES, DATES: ______-______
REASON FOR TERMINATING MEMBERSHIP: ______
ARE YOU CURRENTLY A MEMBER OF A VOLUNTEER FIRE SERVICE OR AMBULANCE CORPS?
IF YES, PLEASE LIST, INCLUDING STARTING SERVICE DATE: ______
______
LIST BELOW ANY PREVIOUS EXPERIENCE, INCLUDING:
NAME AND ADDRESS OF ORGANIZATIONS, LENGTH OF SERVICE, REASON FOR LEAVING AND A REFERENCE FROM EACH (INCLUDE POSITION, NAME, ADDRESS AND PHONE FOR EACH REFERENCE):
______
(ATTACH ADDITIONAL SHEETS IF NECESSARY)
FIRE FIGHTING OR EMS EXPERIENCE (continued):
LIST BELOW ANY APPROVED FIRE SCHOOLS, MEDICAL COURSES AND CERTIFICATIONS YOU HAVE SUCCESSFULLY COMPLETED AND CURRENTLY HOLD:
FIRE COURSES:
FIRE FIGHTER I OR II: ______OTHERS:______
EMS COURSES:
EMT LEVEL: ______CARD #______PLACE TAKEN: ______EXPIRES:______CPR:______EXPIRES:______OTHERS:______
NOTE: APPLICANTS MUST PRODUCE CERTIFICATES UPON REQUEST
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MEDICAL
LISTED BELOW IS A BRIEF DESCRIPTION OF THE DUTIES AN ACTIVE MEMBER OF THIS DEPARTMENT MAY BE EXPECTED TO PERFORM. THIS IS NOT AN INCLUSIVE LIST AND IS ONLY MEANT TO BE REPRESENTATIVE.
1. CLIMBING (INCLUDING AERIAL LADDERS)
2. LIFTING AND CARRYING HEAVY (100+ LBS) OBJECTS OVER A DISTANCE
3. CRAWLING ON HANDS AND KNEES
4. USING SELF CONTAINED BREATHING APPARATUS
5. WORKING IN UNTENABLE ATMOSPHERES AND IN HAZARDOUS SITUATIONS
ARE YOU AWARE OF ANY INJURY, MEDICAL, OR PHYSICAL CONDITION(S) WHICH WOULD LIMIT OR IMPAIR YOUR ACTIVE PARTICIPATION OR ABILITY TO PERFORM DUTIES IN THIS DEPARTMENT? ______YES ______NO
IF YES, PLEASE INDICATE NATURE OF INJURY OR CONDITION AND DATE OF OCCURRENCE:
______
MEDICAL (continued)
DO YOU NOW, OR HAVE YOU IN THE PAST, EXPERIENCED ANY OF THE FOLLOWING:
BACK PROBLEMS ______YES ______NO RESPIRATORY PROBLEMS:
HEART PROBLEMS ______YES ______NO ASTHMA ______YES ____NO
KNEE PROBLEMS ______YES ______NO BRONCHITIS ______YES ____NO
LEG PROBLEMS ______YES ______NO EMPHYSEMA ______YES ____NO
ARM/HAND PROBLEMS ______YES ______NO OTHER: ______
ARTHRITIS ______YES ______NO ______
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EMERGENCY NOTIFICATION
NAME: ______RELATIONSHIP:______
ADDRESS:______
DAYTIME PHONE : ______NIGHT PHONE: ______
SHOULD WE NOTIFY THIS PERSON IN THE EVENT OF A MINOR INJURY? ______
WHAT IS YOUR BLOOD TYPE? ______
---- DO NOT WRITE BELOW THIS LINE ---
DATE INVESTIGATED: ______
MEMBERSHIP INVESTIGATING COMMITTEE MEMBERS PRESENT:
______
______
______
ADDITIONAL COMMENTS: ______
DOCTOR’S APPROVAL REC’D: ______
FIREMATIC APPLICANT: DATE OF VOTE:______VOTE _____YES _____NO _____ABS
DATE RESIGNED: ______TERMINATED: ______
REASON:______
______
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