GARDINER FIRE
DEPARTMENT, INC.
APPLICATION
FOR MEMBERSHIP
DATE
of APPLICATION: _________________________
REGULAR
MEMBERSHIP______________ (or) CADET MEMBERSHIP_____________
(under
18)
(Print Last Name)
(Print First
Name)
(Print
M.I.)
(Print Residential Address - Physical Street, City, State, Zip)
TEL NO: HOME: _______________ WORK:
_______________ CELL: ________________
DATE OF BIRTH:
__________________ SOCIAL SECURITY #
______________________
DRIVERS
LICENSE # _______________________EXP. DATE: ____________CLASS: _____
All
applicants will be subject to a Department of Motor Vehicles check by the Fire
District.
Do
you agree to allow this Department of Motors Vehicles check? Yes ____ No ____
Except
for minor traffic violations and adjudications as a youthful offender, have you
been convicted of an offense against the law? Yes
____ No ____
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 ____
If
so, List previous name(s) and reason for change: __________________________________________________
(Necessary
to enable a background check on your application)
How
long has applicant lived at the above address? _______________
Are
you a citizen of the
If no Country of Citizenship: ______________________________
If
you are not a citizen of the
permanently
in the
Are
you currently employed? Yes ____ No ____ Occupation/Employer _________________ / _________________________
Are you available to participate in normally required fire department
activities. (meetings, drills, emergency calls) Yes ____No
_____
My normal availability is:
Weekdays: Days _____ Nights _____
Weekends: Days
_____ Nights _____
Have
you ever been affiliated with another emergency services organization? (fire
department, police agency, or emergency medical agency) Yes
____ No ____
Reason
for leaving or termination? _____________________________________
Name
of Agency __________________________________________________
Address
_________________________________________________________
Duties
________________________ Contact Person _________________ Phone # ___________
Please
list three references, 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: __________
(Print)
Name:
________________________ Signature:
_____________________ ___Date: __________
(Print)
Name:
________________________ Signature:
________________________Date: __________
(Print)
APPLICATION
FEE: $ 3.00 is required with
this Application
Paid
/ Received By: ________________________________
I
HAVE READ THE APPLICATION ENTIRELY AND THE INFORMATION IS CORRECT TO THE BEST
OF MY KNOWLEDGE.
Applicant Signature:
______________________________________
Date: _____________
Parent
or Guardian Signature (for cadets only) __________________ Date: _____________
Application Received By: __________________________________ Date: _____________
CADET MEMBERSHIP
ONLY ADDITIONAL REQUIRED INFORMATION
Name
of Parent or Guardian: ______________________________________________________
Address
of Parent or Guardian if different from applicant:
_______________________________
Phone
Number and contact in case of Emergency: _____________________________________
School
and Grade Attending: __________________________________________________
Currently
Employed: Yes ____ No _____ With Whom:
______________________
Who
referred you to the Cadet Program? __________________________________________
Do
you have family already in Fire / Rescue / Emergency Service: Yes______ No
______
If
so, who and where do they serve: _____________________________________________
Briefly
describe why you want to join the cadet program:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have
you read, understood and agree to abide by the Cadet
Rules and Regulations set
forth
by the Gardiner Fire Department.
Yes _____ No _____
Having
read the Cadet Rules and Regulations
the parent(s) or guardian(s) give
full
permission to the applicant to participate in this program; state that the
applicant
is in good physical health and agrees to take responsibility for monitoring
the
applicants school performance to the parent(s) or guardian(s) satisfaction.
PARENT or GUARDIAN MUST ATTEND
INVESTIGATING COMMITTEE MEETING with applicant.
I
HAVE READ THE CADET APPLICATION PORTION ENTIRELY AND THE INFORMATION IS CORRECT
TO THE BEST OF MY KNOWLEDGE.
Applicant Signature: __________________________________ Date: ______________
Parent
or Guardian Signature: ___________________________ Date: ______________
-----------------------------------------------------------------------------------------------------------------
Date
of Investigating Committee Meeting: _______________________________
Vice
President:
____________________________________________________________________________
(Print
Name)
(Signature)
(Date)
Assistant
Chief:
____________________________________________________________________________
(Print
Name)
(Signature)
(Date)
Rescue
Lieutenant:
____________________________________________________________________________
(Print
Name) (Signature)
(Date)
Cadet
Program Manager (for Cadets only):
____________________________________________________________________________
(Print
Name) (Signature)
(Date)
Date
voted in by the Gardiner Fire Department: ________________
Signed
by President: ______________________________________
Date accepted by the Gardiner Fire District: ___________________
Signed by Commissioner: __________________________________
FOR
OFFICE USE ONLY BELOW THIS LINE
Dues
Paid: _______________ Background Check: _____________
License
Copy: ____________ Signature _________
Reference
Check: _________ Investigating
Committee: _________