GARDINER FIRE DEPARTMENT, INC.

P.O. Box 271

Gardiner, New York, 12525

 

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)

Mailing Address (If Different From Above): _______________________________________________________________________________________________________________________

 

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 County Sheriff for processing through DCJS. (Required by New York State Executive Law Section 837-0)

Do you agree to allow this Arson Conviction Record Check?           Yes ____ No ____ 

Have you ever been known by any other name? (Marriage etc.)        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? _______________

How long has applicant resided in New York State? _______________

Are you a citizen of the United States?                                              Yes ____ No ____

If  no Country of Citizenship: ______________________________

If you are not a citizen of the United States, do you have the legal right to remain

permanently in the United States?                                                      Yes ____ No ____

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: _________                                                        

 

 GFD APP:07212011