Brazoria Fire Department

BRAZORIA FIRE DEPARTMENT

Application for Membership

Application Type: Active Membership

Full Name:______DOB:______TDL:______

SSN:______Home Ph.:______Work Ph.:______

Sex:______Ht:______Wt:______Eyes:______Hair:______

Marital Status:______Spouse’s Name:______

# Children:______Employer:______How Long:_____

Emergency Contact:______Home Ph:______

Address:______Work Ph:______

City/State/Zip:______Relationship:______

Length of Residence in Brazoria Area:

Have you been convicted of any crimes other than traffic: YesNo

If yes, please explain:______

______

Do you mind if we perform a background check? Yes No

List any previous firefighting experience (Dept., Chief, Dates, City):

______

List any certifications held in firefighting:

______

Are you a member of organizations that meet on Thursdays? If yes, list below:

______

Please list the reasons you wish to join this organization?

______

What is your physical condition? ______

(Yes /No) Back ? ______Heart ______High Blood Pressure ______Diabetes ______

Do you have any respiratory conditions that might be affected by smoke or other gases? ______

If yes please explain:______

Are you afraid of close spaces? ______

You may be required to take a Drug test and Physical as a member of BVFD.

Are you willing to take a Drug test ? ______

Are you willing to take a Physical?. ______

Will you be willing to assist in fund raising activities or any other non-firefighting activities in which the department may participate?______

Does your spouse have any reservations about your being a firefighter?______

Are you aware of the hazards involved in firefighting?______

Will you be willing to spend time other than on drill nights to maintain equipment, station or train?______

Please list any other skills or training that you may have that has not been previously listed

______

I do hereby agree to abide by the policies, rules, and by-laws of the Brazoria Volunteer Fire Department and I further give the Brazoria Volunteer Fire Department authorization to investigate my background, up to and including a criminal history check.

Printed Name:______Date:______

Usual Signature:______

In order to be considered for membership, you must be recommended by two members who are in good standing.

______

Member’s Signature Member’s Signature

Departmental Use Only:

Application Committee Notes:

______

Application Committee’s Recommendation:

______Yes ______NoCommittee Member: ______

Special Probationary Requirements:______

______

Probationary Period : ______Date of Completion: ______

Date Accepted by Membership Vote:

Change in Member Status:

Active InactiveExemptSuspended

Termination Resignation AssociateDeceased

Date of Status Change:______Reinstatement Date If Applicable:______

Comments: ______

______

ConfidentialPage 1Date Revised: 01/31/04