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01/30/2023 0358 |
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 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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01/30/2023 0358 |
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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