GARDINER FIRE DEPARTMENT, INC.

P.O. Box 271

Gardiner, New York, 12525

 

APPLICATION FOR MEMBERSHIP

 

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 New York State? ______________

 

Are you a citizen of the United States?  Yes ____ No ____      If not Country ______________

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 _________________

 

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 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 ____

 

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: ______________________

 

FOR OFFICE USE ONLY BELOW THIS LINE

 

Dues Paid: ____           Background Check: ____         License Copy: ____     Signature ____

Reference Check: ____            Investigating Committee: ____                                                  jb12/02/2003