GARDINER FIRE DEPARTMENT, INC.
DATE: ____________
(Last Name) (First Name) (M.I.)
(Street Address)
TELEPHONE # HOME: _________________ WORK: _________________
DATE OF BIRTH: __________________ SOCIAL SECURITY # __________________
DRIVERS LICENSE # _______________ EXPIRATION DATE: __________ CLASS: ______
Except for minor traffic violations and adjudications as a youthful offender, have you been convicted of an offense against the law? Yes ____ No ____
You may be subject to a Department of Motor Vehicles check by the Fire District insurance company.
Do you agree to allow this check? Yes ____ No ____
How long have you resided at the above address? ____________
How long have you resided in
Are you a citizen of the
If you are not a citizen of the
permanently in the
Are you currently employed? Yes ____ No ____ Occupation _________________
Please indicate your availability to participate in normally required fire department activities. (meetings, drills, emergency calls) (yes or no)
Week Days _____ Nights _____
Weekends Days _____ Nights _____
Have you ever been affiliated with another emergency services organization? (fire department, rescue squad, police, or other emergency medical agency) Yes ____ No ____
Reason for leaving or dismissal? _____________________________________
Name of Agency __________________________________________________
Address _________________________________________________________
Duties ________________________ Contact Person _________________ Phone # ____________
Have you ever been known by any other name? (Marriage etc.) Yes ____ No ____
If so, List name(s) and reason. (Necessary to enable a background check on your application)
All applicants for membership to volunteer fire companies,
or transfers from one company to another, must submit
to an arson conviction record check by filling out a Division of Criminal
Justice Services (DCJS) form designated for this purpose prior to election and
acceptance as a new member. This form will be forwarded to the
Do you agree to allow this Arson Conviction Record Check? Yes ____ No ____
Please list three references, preferably people who have known you for at least 3 years.
(non fire department members)
Name: _________________________ Telephone # _______________
Address: ______________________________________________________
Name: _________________________ Telephone # _______________
Address: ______________________________________________________
Name: _________________________ Telephone # _______________
Address: ______________________________________________________
Three signatures are required from members of the Gardiner Fire Department.
(non Investigating Committee Member)
Name: _________________________ Signature: _________________________ Date: _______
Name: _________________________ Signature: _________________________ Date: _______
Name: _________________________ Signature: _________________________ Date: _______
Application Fee of $ 3.00 required with this Application Paid / Received By: ______________
I HAVE READ THE ABOVE AND THE INFORMATION IS CORRECT TO
THE BEST OF MY KNOWLEDGE.
Applicant Signature: _________________________ Date: __________
Application Received By: _____________________ Date: __________
Date of Investigating Committee Meeting: __________
Vice President: ______________________________________________________________________
(Print Name) (Signature) (Date)
Assistant Chief: ______________________________________________________________________
(Print Name) (Signature) (Date)
Rescue Lieutenant: ____________________________________________________________________
(Print Name) (Signature) (Date)
Date voted in by the Department: ____________ Signed by President: __________________________
Date accepted by the Fire District Board: ________ Signed by Commissioner: ______________________
Dues Paid: ____ Background Check: ____ License Copy: ____ Signature ____
Reference Check: ____ Investigating Committee: ____ jb12/02/2003