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Mon, Aug 27th, 2018 12:00:00 pm -

Southwood Volunteer Fire Department, Inc.

Application for Membership

4581 Grace Place, Jamesville,NY 13078


1. Date of application _______________

2. Name ___________________________________________________

3. Address _________________________________________________

4. How long at present address _________________________________

5. Previous address __________________________________________

6. Home Phone____________ cell_____________ Email_____________

7. What position are you applying for? Firefighter, Fire Police, EMS, support Services. Please circle all that you are interested in.

8. Have you ever had training in any of the above circled? Yes___No___

9. Previous emergency experience: (fire, rescue, fire police and emergency medical service agencies). Circle any of the above and attach all copies of certificates.

10.Name of Agency____________________________________________ Address_____________________________________________________

Contact person________________________Telephone_______________

11. Please indicate your availability to participate in fire department activities: (meetings, drills, emergency calls).

Week Days: Days_____ Evenings______Nights_____

Weekends: Days_____ Evenings______Nights_____

12. Is additional information about a change in your name, use of an assumed name, or nickname necessary to enable a check on your eligibility for membership? Yes_____ No_____ If yes, please explain.

____________________________________________________________ ____________________________________________________________ ____________________________________________________________

13. Do you have a valid New York State Drivers License? Yes____No____

14. Are you currently employed? Yes____ No____

If yes, may we contact your employer as a reference? Yes___No____

Name of Company__________________________________________


15. Military Service: Yes____ No_____ If yes, Please attach a DD214

16. Please list 3 personal references other than the members of this organization, who have known you for 2 or more years.

A.__________________________________________________________ B.__________________________________________________________ C.__________________________________________________________

OSHA regulations require that you pass a physical examination before becoming an interior structural firefighter and or EMS personnel. The departments designated physician will provide you with a FREE medical examination as well as updates on Tetanus shots. Would you be willing to take a medical examination? Yes______ No_______

17. The Southwood Fire Department requires a back ground check on all personnel entering our fire department. Back ground checks include: Criminal, Terrorist, Child predators, Felony, Arson and DMV. Would you consent to a background check? Yes____ No_____

Within the Freedom of Information Law, all information contained or obtained herein will remain confidential and will be used only for internal membership processing.

Privacy Notification:

Section 94 of the Public Officers Law (Personal Privacy Law) requires that you be notified of the following facts when information which will be maintained in a record system is collected from you.

The authority to request and confirm personal information about you is found in Article 6 of The Executive Law.

The information obtained will:

Be used to determine your qualifications for the position for which you are applying.

Be maintained in your personnel folder.

Failure to provide the information or authorization will result in your application not being considered for membership.

The information will be maintained by the Chief / officers of The Southwood Fire Department.

In witness whereof, this application has been subscribed this ____day of _________, 20__. By the undersigned applicant who affirms that the statements made herein are true under the penalties of perjury.

Applicant’s signature___________________________________________


Witnessed by_________________________________________________


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