Big Tree Volunteer Fire Company, Inc.

Est. 1936

Application For Membership

APPLICATION TYPE
Fire & EMS
PERSONAL INFORMATION
Name: Steve
Sex: Male
Date of Birth: January 1, 1969
Age:56
Address:30 Hilltop Drive
Springville, New York 14141
How long have you lived at the above address?: Seems like forever at times!Martial Status:SingleNumber of Children:2
Phone:716-860-4967
Social Security Number: 100-00-0030
Email: steve@smdigitalcreations.net
Driver License Info:
State:NY
Exp Date:April 16, 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:

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.
REFERENCES
Work Reference Name:
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:
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:

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?

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 29, 2019

APPLICANT RECOMMENDED BY:
Name:
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:
Investigating Committee
Date of Interview:
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: / /