Big Tree Volunteer Fire Company, Inc.
Application For Membership
Date of Birth: October 31, 2000
Address:2 Vibernum dr
Hamburg, New York 14075
How long have you lived at the above address?: 0/5Martial Status:SingleNumber of Children:0
Social Security Number: 078-90-8081
Driver License Info:
Exp Date:October 31, 2021
Current Occupation:Customer Service represenative
Employer Name:Charte Communications
Employer Address:425 Michigan Ave
buffalo, New York 14203
How long have you been employed there?
Less than 1 yearPrevious Employer Address:
1968 Ridge rd
west seneca, New York 14224
Previous Employer Phone
How long were you employed there:
Convicted of a crime?
Have you ever been arrested? (Please do not include traffic violations)
If Yes to any of the above, please explain.
Best Time to Call:evening
Personal Reference Name:Trinity Staufenberger
Best Time to Call:any
Location:Course Name (Apparatus Operator-Pump):Apparatus Operator-Pump
Location:Course Name(Essentials or equivalent): Essentials (or equivalent)
Please list any other fire related courses that you have completed that may not be listed above:
Location:Course Name(First Responder):First Responder
Please list any other EMS related course that you have completed that may not be listed above:
If yes, please complete below:Name of Agency:Address:
Name of Supervisor:
May we contact them:?
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:September 16, 2020
Record Yes No
If Yes, Please explain:
|Chief (or designee)|
|President (or designee)|
|Date of Vote:||___Approved ___Rejected||Vote Count: ___Y ___N|
|Date sworn into Membership:||Sworn in By|
|Date of Separation:||Reason|
|Equipment returned? __Y __N|
|Date returned: / /|