Horseheads Fire Department Membership Application

HORSEHEADS FIRE DEPARTMENT

134 N. MAIN ST

HORSEHEADS, NEW YORK 14845

APPLICATION FOR MEMBERSHIP

NAME_______________________________________________________

(last) (first) (middle)

ADDRESS____________________________________________________

PHONE______________SOCIAL SECURITY NUMBER_________________

Are you 18 years of age or older? Yes_______ No_____________________________

Has any court ever convicted you, including a court of military justice, of a felony or misdemeanor? Yes_______ No________ if yes, state date, place, and nature of each conviction._______________________________________________________________

________________________________________________________________________

Are you a graduate from High School? Yes_____________ No__________________

From what High School did you graduate? Yes___________ No_________________

From what college(s) did you graduate? Yes___________ No___________________

Did/do you serve in the armed forces? Yes___________ No____________________

If yes, what branch? ______________________________________________________

Please list below, any schools related to Fire Science, First Aide or other specialized training you have completed. _______________________________________________________________________

_______________________________________________________________________

(use back of page if additional space is needed)

AGREEMENT

I realize that if _________________________________________ is accepted for membership in the Horseheads Fire Department, he/she will be giving part of their time to public service. I further realize that giving some form of public service is the duty of every citizen and I hereby give my consent to this application.

SIGNATURE_________________________________________DATE_____________

(wife, parent or guardian)

The information on this application is true to the best of my knowledge and belief and I understand and agree that any misrepresentation or false statement by me in connection with this application will constitute justifiable cause for the Horseheads Fire Department to terminate my membership.

I understand and agree that all information furnished by this application may be verified by the Horseheads Fire Department. I hereby authorize all individuals and organizations to give the Horseheads Fire Department all information relative to such organizations and the Horseheads Fire Department from any and all liability for any claim or damage resulting there from.

If elected to membership, I agree I will serve at the will of the Company and Department. I agree that the rules, policies and regulations of the Company and Department shall bind me, as they are from time to time changed with proper notification to me.

I___________________________________ give permission to the Horseheads

(print name)

Fire Department to further investigate me by any police agency necessary for the approval or dismissal of me becoming a member of the Horseheads Fire Department.

SIGNATURE REQUIRED________________________________________________

SIGNATURE OF EMPLOYER____________________________________________

PROPOSER’S SIGNATURE______________________________________________

APPLICANT’S SIGNATURE_____________________________________________

APPLICANT’S FEE ($5.00) PAID________________ NOT PAID________________

RECEIVED BY ___________________________________________________

APPLICATION RECEIVED DATE________________________________________

APPLICATION ACCEPTED DATE________________________________________

Are you currently employed? Yes___________________ No___________________

If yes, name of employer___________________________________________________

Occupation_____________________________ Length of time employed____________

Married____________ Single____________ Number of dependents_________________

Spouse’s name___________________________________________________________

References

May be friends or relatives in the Fire Department

1. _____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________

(name) (address) (phone)

Have you ever been a member of a paid or volunteer Fire Department? Yes___ No___

If yes, where? ____________________________________________________________

Do you realize that the Fire Department is not a social club and that as a member you are required to give freely of your time to attend all fire calls, drills, meetings and work on committees? (signature required) ____________________________________________

Who to notify in case of emergency __________________________________________

(name)

_______________________________________________________________________

(phone) (relationship)

Do you have any impairment, physical, mental or medical that would prevent you from functioning in the position of Firefighter?______________________________________

Are you willing to take a physical examination as required by the Horsehads Fire Department? Yes_______________ No_______________

Do you have a valid driver’s license? Yes _______________ No_________________

If yes, list the motorist I.D. number___________________________________________

SECRETARY'S SIGNATURE______________________________________________

COMMITTEE APPOINTED

Sign Below

1. _____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________

4. _____________________________________________________________________

LETTER TO VILLAGE BOARD (date) _______________________________________

ACCEPTED BY VILLAGE BOARD (date) ____________________________________

1-year probation up & voted on (date) _________________________________________

POLICE RELEASE

TO: Horseheads Police Department

FROM: Horseheads Fire Department

RE: Records Check

PRINT CLEARLY:

Name___________________________________________________________________

(last) (first) (middle) (maiden)

Date of Birth__________________/____________________/______________________

Address_________________________________________________________________

(street) (city) (state)

Social Security # ________________-_________________-_______________________

I hereby authorize the Horseheads Police Department to release any criminal records and/or police contacts pertaining to myself on file at any Police agency Office or other office to which I was a member (I.E. Fire Dept.)

________________________________________________________________________

(signature) (date)

________________________________________________________________________

TO BE COMPLETED BY THE HORSEHEADS POLICE DEPARTMENT

The above named person shows criminal record on file at:

Elmira Heights PD Yes______ No______ CCSD Yes______ No___

Elmira PD Yes______ No______ HHDS PD Yes______ No___

West Elmira PD Yes______ No______ N.Y.S.P. Yes______ No___

The above named person has attached record(s) on file at the office(s) check marked, Yes.

Signature________________________________________________________________

Title____________________________________________________________________

Date records check conducted_______________________________________________

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