The Volunteer Fire Company of Halfway, MD, Inc.

APPLICATION FOR MEMBERSHIP

Please Print and mail or Fax this to the address below:
 
11114 Lincoln Ave., Hagerstown, MD 21740
Phone: 301-582-2223   Fax: 301-582-1075

Date of Application:

POSITION (S) APPLIED FOR:    
  Firefighter   Emergency Medical Services   Junior Member (16-17 years old)   Cadet Member (15 years old)
 
  Fund Raiser / Bingo   Administration   Other:
 
PERSONAL INFORMATION:
Name:

SSN:
  LAST FIRST MIDDLE    
Address: ,  
  NUMBER STREET APT#  
  ,  
  CITY STATE ZIP CODE  
         
Phone: (H) (C) (W) (P)  
           
Date of birth (Used for LOSAP purposes only) / /  
  MONTH   DAY   YEAR  
Have you filed an application here before?   YES   NO If yes, give date: / /  
        MONTH   DAY   YEAR  
Have you ever been employed by or been a member of a Fire Department?   YES   NO  
If Yes, please list below:
  Company Name Address Time employed / active Reason for leaving  
#1  
#2  
#3  
#4  
 
 
 
 
 
 
     
Have you ever been employed by or been a member of an Ambulance or Rescue Department?   YES   NO  
If Yes, please list below:      
  Company Name Address Time employed / active Reason for leaving  
#1  
#2  
#3  
#4  
 

* Are you a Veteran?

   YES   NO

If yes, Branch of service: 

* Are you a member of the reserves or National Guard?

   YES   NO  
Branch of Service From-To Occupation:  
       

* Optional Information

      
Have you ever been convicted of a felony?   YES   NO  
If yes, explain:
 
 
 
   
Are you willing to take a physical examination?   YES   NO  
       
Are you willing to undergo an alcohol and / or drug test?   YES   NO  
       
* Education      
  Name Years Completed Diploma / Degree
Grammar School
High School
College/University
Technical School
MFRI / Specialized training
 

**Attach additional pages as necessary.
 
If you did not graduate from high school, have you passed an examination and received a high school equivalency certificate from
Maryland or any other state?   YES   NO  
         
Name of state granting certificate of equivalency: Date of Insurance:  
         
         
         
         
DRIVERS LICENSE INFORMATION:        
** Driver’s License Number Class State of Issue Date of Insurance  
 
** Do you currently have any active motor vehicle "points" on your driving record?   YES   NO If yes, how many?
**This Information must be disclosed ONLY if it is essential to the type of position you are applying for.
 
 
 
       
EMPLOYMENT EXPERIENCE
Start with your present or last job. Include military service assignment and volunteer activities. Exclude organization name which indicate race, color, religion, sex or national origin.
1. Employer:
  Address:
   
  Telephone:
  Dates Employed: From: To:
  Work Performed:
  Job Title:
  Supervisor:
  Reason for leaving:
2. Employer:
  Address:
   
  Telephone:
  Dates Employed: From: To:
  Work Performed:
  Job Title:
  Supervisor:
  Reason for leaving:
3. Employer:
  Address:
   
  Telephone:
  Dates Employed: From: To:
  Work Performed:
  Job Title:
  Supervisor:
  Reason for leaving:
Attach additional pages if necessary.
     

REFERENCES-   Please give us three references ONLY ONE of which is a relative.
#1        
Name Relationship  
Address City/State/ZIP  
Phone Occupation  
 
#2        
Name Relationship  
Address City/State/ZIP  
Phone Occupation  
 
#3        
Name Relationship  
Address City/State/ZIP  
Phone Occupation  
 

Give a brief statement in your own words explaining why you would like to become a member of this department.

 
 
 
 

MEMBERSHIP AGREEMENT

PLEASE READ CAREFULLY

I, an applicant of The Volunteer Fire Company of Halfway, Maryland, Inc., do agree to abide by the rules and regulations, and the organizational By-Laws as set forth by this company.

Furthermore, I understand that I will follow the instructions and / or orders of any officers, and shall endeavor to do such at all times.

I also understand that any materials, patches, badges, gear, any identification of any kind shall not be worn after termination of membership with this Company. Also items deemed property of the Company shall be promptly returned to the Chief, or I may face prosecution.

I also agree and permit The Volunteer Company of Halfway, to make all necessary inquires, and investigations related to the validity of these statements which I made on this application for membership.

I also agree and permit The Volunteer Fire Company of Halfway, to conduct all necessary background checks to assure the potential member is in good standing.

I shall at all times, endeavor as to the best of my ability, to serve, protect, and better the organization of The Volunteer Fire Company of Halfway, Maryland, Incorporated.

I also understand that any misrepresentation or omission of facts made on this application shall be considered as cause for dismissal or refusal into the organization.

 

Signature_______________________________

Parents, if Minor ________________________________

Date __________________________________________

 

APPLICANTS ARE CONSIDERED FOR ALL POSITIONS WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, MARITAL OR VETERANS STATUS, OR PRESENCE OF NON-JOB RELATED PHYSICAL OR MENTAL HANDICAP.

All information on this document will be verified with the applicant to insure he applied to the photo team before he / she is investigated.

The Volunteer Fire Company Of Halfway
Copyright © 2008  All rights reserved.
Revised: 04/05/08