| Membership type I am applying for:
|
 |
Fire Fighter Membership
Social /Auxiliary Membership
EMT / Paramedic Membership
Fire Police Membership
Junior Membership (must be 14 yrs. of age or older)
|
|
| PERSONAL INFORMATION |
|
Name:
Last, First, Middle
|
|
|
| Social Security Number:
|
|
|
| Birth Date:
|
|
|
Address:
Street Address, City, State, Zip Code
|
|
|
| Telephone Number:
|
|
|
| Email Address:
|
|
|
| Are you at least 18 years of age: |
|
No
Yes
|
| If applying for Junior Membership, are you at least 14 years of age and less than 16 years of age: |
|
No
Yes
|
| If applying for Junior Emergency Responder Membership, are you at least 16 years of age?: |
|
No
Yes
|
| How did you find out about Rose Fire Company:
|
|
|
| Do you have any relatives or friends working/volunteering here: |
|
No
Yes
|
| If you do have any relatives or friends working/volunteering here, please list:
|
|
|
|
| CERTIFICATION INFORMATION - (List only current certifications - photocopies are needed at interview)
|
|
CPR:
Certification Number, Expiration Date, Certifying Agency
|
|
|
EMT:
Certification Number, Expiration Date, Certifying Agency
|
|
|
Paramedic:
Certification Number, Expiration Date, Certifying Agency
|
|
|
National Registry:
Certification Number, Expiration Date, Certifying Agency
|
|
|
PALS:
Certification Number, Expiration Date, Certifying Agency
|
|
|
ACLS:
Certification Number, Expiration Date, Certifying Agency
|
|
|
BTLS:
Certification Number, Expiration Date, Certifying Agency
|
|
|
EMD:
Certification Number, Expiration Date, Certifying Agency
|
|
|
CDL:
Certification Number, Expiration Date, Certifying Agency
|
|
|
EVOC/EMS Vehicle Operator:
Certification Number, Expiration Date, Certifying Agency
|
|
|
Other:
Certification Number, Expiration Date, Certifying Agency
|
|
|
| Upload Copies of Certifications:
|
|
|
|
| MILITARY |
|
| Branch of Service :
|
|
|
| Date Began :
|
|
|
| Date Ended :
|
|
|
| Rank & Duties :
|
|
|
| Date Discharged :
|
|
|
| Location:
|
|
|
|
| EDUCATION AND TRAINING |
|
| High School - Name:
|
|
|
| High School - Address:
|
|
|
| High School - Years Completed:
|
|
|
| High School - Did you Graduate: |
|
No
Yes
|
| High School - If you didn't graduate, highest grade completed:
|
|
|
| Have you received your GED: |
|
No
Yes
|
| College - Name:
|
|
|
| College - Address:
|
|
|
| College - Years completed:
|
|
|
| College - Did you graduate: |
|
No
Yes
|
| College - If you did not graduate, highest year completed:
|
|
|
| College - Degree:
|
|
|
| College - Major:
|
|
|
| Other School / Training - Name:
|
|
|
| Other School / Training - Address:
|
|
|
| Other School / Training - Years completed:
|
|
|
| Other School / Training - Did you graduate: |
|
No
Yes
|
| Other School / Training - If you did not graduate, highest year completed:
|
|
|
| Other School / Training - Certificate:
|
|
|
| Other School / Training - Certificate expiration:
|
|
|
| Other School / Training - License:
|
|
|
| Other School / Training - License expiration:
|
|
|
| Other School / Training - Other:
|
|
|
| Other School / Training - Upload Documents:
|
|
|
| EMS/Fire Service-Related Training Not Listed Above:
|
|
|
| EMS/Fire Affiliations:
|
|
|
|
| REFERENCES |
|
Reference #1:
Name, Address, Relation, Years Known, Telephone Number (including area code)
|
|
|
Reference #2:
Name, Address, Relation, Years Known, Telephone Number (including area code)
|
|
|
|
| EMERGENCY CONTACT INFORMATION |
|
Emergency Contact:
Name, Relationship, Day Phone Number, Evening Phone Number
|
|
|
|
| ACKNOWLEDGMENT |
|
| Electronic Signature of Applicant:
|
|
|
| Electronic Signature of Parent or Legal Guardian (if under 18):
|
|
|
By signing my electronic signature above,I certify that the information I have given on this application is true, complete, and correct, and I understand that any false information or the omission of information may be considered as sufficient reason for my discharge if I become a member or employee. I recognize that completion of this application does not mean that I will be accepted as a member and does not bind Rose Fire Company to accept me as a member. Applications will remain active for six months, after which time re-application will be necessary. If accepted for membership, I agree to abide by all rules, regulations and policies established by Rose Fire Company and its officers and other persons in charge. I understand that, if accepted as a member, my membership is voluntary and may be terminated in accordance with the Rose Fire Company Bylaws, policies, procedures and all applicable laws and regulations. This application is not an agreement or a contract for membership.
I hereby authorize Rose Fire Company to inquire about my volunteer history with former volunteer organizations and to make any further inquiries considered necessary in connection with my application for membership, including a criminal history check, driving history check, child abuse clearance check, elder abuse clearance check, FBI background check, and other such inquiries. I release Rose Fire Company and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished
|
