Position(s) applied for:

______ Firefighter _______ Fund Raiser / Bingo

______ Emergency Medical Services _______ Administration

______ Junior Member (16-17 years old) _______ Other ______________

______ Cadet Member (15 years old)

Name:_________________ __________________ ____________SSN: ________-_______-______

Last First Middle

Address: __________________________________________________________________________

Number ________________ Street _____________________

City __________________ State _______ Zip code ___________

Phone: (H) _________________ (W) _________________ (Pager) __________________

Date of birth (Used for LOSAP purposes only) _______/_______/________

Have you filed an application here before? ____ Yes ____ No If yes, give date _______________

Have you ever been employed by or been a member of a Fire Department? ____Yes ____No

If yes, give name, address, time employed / active and reason for leaving.

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Have you ever been employed by or been a member of an Ambulance or Rescue
department? ____Yes ____ No

If yes, give name, address, time employed / active and reason for leaving.

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

* Are you a Veteran? _____Yes _____No

* 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 _____________

** 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.

____________________________________________________________________________

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:____________

   Worked Performed: ____________________________________________________

   _______________________________________________________________________

   Job Title: ___________________________________________________

   Supervisor: _________________________________________________

   Reason for leaving: ____________________________________________________

   _______________________________________________________________________

   _______________________________________________________________________

3. Employer: __________________________________________________

Supervisor: _________________________________________________

Reason for leaving: __________________________________________________________

50

_____________________________________________________________________________

Attach additional pages if necessary: _____________________________________________________________________________

Please give us three references ONLY ONE of which is a relative.

Name ________________________________ Relationship _____________________________

Address _______________________________ City/State _____________________________

Phone _________________________________ Occupation _____________________________

Name ________________________________ Relationship _____________________________

Address _______________________________ City/State _____________________________

Phone _________________________________ Occupation _____________________________

Name ________________________________ Relationship _____________________________

Address _______________________________ City/State _____________________________

Phone _________________________________ Occupation _____________________________

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

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

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 ORGIN, AGE, MATIRAL OR VETERANS STATUS, OR PRESENCE OF NON-JOB RELATED PHYSICAL OR MENTAL HANDICAP.