Big Tree Volunteer Fire Company, Inc.
Est. 1936
Application For Membership
APPLICATION TYPE
EMS Only
PERSONAL INFORMATION
Name: Marie
Sex: Female
Date of Birth: January 1, 1969
Age:50
Address:TEST
Marilla, New York 14102
How long have you lived at the above address?: 11508 Renee CourtMartial Status:SingleNumber of Children:4
Phone:716-805-0124
Social Security Number: 222-22-2222
Email: contact@smblu.com
Driver License Info:
State:NY
Exp Date:April 26, 2019
Sex: Female
Date of Birth: January 1, 1969
Age:50
Address:TEST
Marilla, New York 14102
How long have you lived at the above address?: 11508 Renee CourtMartial Status:SingleNumber of Children:4
Phone:716-805-0124
Social Security Number: 222-22-2222
Email: contact@smblu.com
Driver License Info:
State:NY
Exp Date:April 26, 2019
EMPLOYMENT INFORMATION
Previous Employer Name:
Current Occupation:
Employer Name:
Employer Address:
Employer Phone:
Normal Hours:
How long have you been employed there?
Previous Employer Address:
Current Occupation:
Employer Name:
Employer Address:
Employer Phone:
Normal Hours:
How long have you been employed there?
Previous Employer Address:
Previous Employer Phone
How long were you employed there:
CRIMINAL HISTORY
Have you ever been charged with a crime?
No
Convicted of a crime?
No
Have you ever been arrested? (Please do not include traffic violations)
No
If Yes to any of the above, please explain.
No
Convicted of a crime?
No
Have you ever been arrested? (Please do not include traffic violations)
No
If Yes to any of the above, please explain.
REFERENCES
Work Reference Name:
Relationship:
Phone:
Best Time to Call:
Personal Reference Name:
Relationship:
Phone:
Best Time to Call:
Relationship:
Phone:
Best Time to Call:
Personal Reference Name:
Relationship:
Phone:
Best Time to Call:
FIREMATIC TRAINING
Course Name (essentials or equivalent):Essentials (or equivalent)
Date:
Location:Course Name (Apparatus Operator-Pump):Apparatus Operator-Pump
Date:
Location:Course Name(Essentials or equivalent): Essentials (or equivalent)
Date:
Location:
Please list any other fire related courses that you have completed that may not be listed above:
Date:
Location:Course Name (Apparatus Operator-Pump):Apparatus Operator-Pump
Date:
Location:Course Name(Essentials or equivalent): Essentials (or equivalent)
Date:
Location:
Please list any other fire related courses that you have completed that may not be listed above:
EMERGENCY MEDICAL SERVICES (EMS) TRAINING
Course Name(CPR/AED):CPR/AED
Date:
Location:Course Name(First Responder):First Responder
Date:
Location:Course Name(EMT-B):EMT-B
Date:
Location:Course Name(AEMT-I):AEMT-I
Date:
Location:
Date:
Location:Course Name(First Responder):First Responder
Date:
Location:Course Name(EMT-B):EMT-B
Date:
Location:Course Name(AEMT-I):AEMT-I
Date:
Location:
Course Name(AEMT-P):AEMT-P
Date:
Location:
Please list any other EMS related course that you have completed that may not be listed above:
FIRE or EMS SERVICE EXPERIENCE
Have you ever been a member of another Fire Company/Department or Emergency Medical Services Provider?
No
If yes, please complete below:Name of Agency:Address:
Name of Supervisor:
No
If yes, please complete below:Name of Agency:Address:
Name of Supervisor:
Phone:
May we contact them:?
AFFIRMATION OF INFORMATION ACCURACY
By checking this box I attest to the foregoing information as true and accurate.
To the best of my knowledge, the foregoing information is true and accurate.
Date:April 12, 2019
APPLICANT RECOMMENDED BY:
Name:
Rank/Title:
Rank/Title:
OFFICE USE ONLY
Date application was received by Secretary:
Police Record Check
Date Performed:
Performed By:
Record Yes No
If Yes, Please explain:
Performed By:
Record Yes No
If Yes, Please explain:
Investigating Committee
Date of Interview:
Approved Rejected
Approved Rejected
| Name | Title | Signature |
| Secretary | ||
| Chief (or designee) | ||
| President (or designee) | ||
| Head Trustee | ||
| Trustee | ||
| Trustee | ||
| Trustee | ||
| Trustee |
Fire Company Action
| Date of Vote: | ___Approved ___Rejected | Vote Count: ___Y ___N |
Applicant
| Date sworn into Membership: | Sworn in By |
| Date of Separation: | Reason |
| Equipment returned? __Y __N[131] | |
| Date returned: / / |