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06/10/2023 0102 |
| Desired Interest?: |
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FIRE
EMS
FIRE & EMS
N/A
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Full Name:
First, Middle, Last Name
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| Home Phone:
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| Cell Phone:
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| Email Address:
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Address:
Street Address, City, State, Zip Code
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| How long have you lived at this address?:
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| Social Security Number:
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| Date of Birth:
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| Age:
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| Do you have a high school diploma or GED?:
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| Name of School:
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| Location of school:
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| Month / Year Graduated:
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Marital Status:
(Optional)
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| Employer:
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Employer Address:
Street address, City, State, Zip Code
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| Work Hours:
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| Work Phone:
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| Next of Kin:
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| Relationship:
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| Phone Number:
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| Do you have any handicaps or medical conditions:
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| If Yes, Explain:
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| Have you ever been arrested?:
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| If Yes, explain in detail:
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| Have you been in the Military Services?:
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| If so, what type of discharge did you receive?:
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| Have you ever been a member of a volunteer Fire Department or Rescue Squad?:
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| If previous member in Maryland, provide LOSAP Number:
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Attach LOSAP records:
If you have your county LOSAP records, please attach them here.
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| Name of Department:
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Department Address:
Street Address, City, State, Zip Code
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| Chief Officer:
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Have you ever had any prior training in Firefighting or First Aid?:
If so, please attach copies of training records
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Training Records:
Please attach any training records you have
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| Do you have a Maryland drivers license?:
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| Driver's License Number:
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| License Class:
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| Has your license ever been suspended or revoked?:
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| If license has been suspended or revoked, please explain:
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Membership Status you are applying for:
Note: If you are the age of fifteen (15) and have not yet reached the age of sixteen (16) you are eligible for Cadet member status. If you are between the ages of sixteen (16) and eighteen (18), you will serve as a Junior Member until you reach your eighteenth (18) birthday. You must have parental consent to join. All members must serve a nine-month probationary period before being voted as an active member by the membership.
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| References (Please list three (3) personal references who are not relatives) |
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Reference #1:
Name, Address, Phone Number
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Reference #2:
Name, Address, Phone Number
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Reference #3:
Name, Address, Phone Number
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| Remarks:
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Applicant Electronic Signature:
I understand that selecting the electronic signature constitutes a legal agreement/signature confirming that I acknowledge and agree to the terms of the application and consent to a background check.
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| Date Application Submitted:
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06/10/2023 0102 |
Parent/Guardian Signature:
If you are between the ages of Sixteen (16) and Eighteen (18), you will serve as a Junior Member until you reach your Eighteenth (18th) Birthday. You must have parental consent to join. Parent/Guardian may be required to attend membership meeting and actual signature will be required.
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| Parent/Guardian Date Signed:
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| I hereby acknowledge the receipt of ByLaws of this organization:
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| Date of ByLaws received:
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I understand that signing the electronic signatures above constitutes a legal signature confirming that I acknowledge and agree to the Terms of the application below and consent to a background check.
If accepted as a member, I will abide by the ByLaws and upon termination of my membership I will return any and all property belonging to the Second District Volunteer Fire Department and Rescue Squad.
I authorize the investigation of all statements contained in this application. I understand that misrepresentation or omission of factions called for is cause for non-acceptance or dismissal. Further, I understand the requirements and duties of being a member of the Second District Volunteer Fire Department and Rescue Squad, Inc. and agree that the failure to meet or fulfill these requirements, are reason for dismissal or other actions. I further certify, if under the age of 18, I have permission of my parents or guardian to join the Second District Volunteer Fire Department and Rescue Squad, Inc.
Note: If you are between the ages of Sixteen (16) and Eighteen (18), you will serve as a Junior Member until you reach your Eighteenth (18th) Birthday. You must have parental consent to join. All members must serve a nine-month probationary period before being voted as an active member by the membership.
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