NAME SOCIAL SECURITY NUMBER DATE OF BIRTH First Middle Last ADDRESS CITY COUNTY STATE ZIP HOME PHONE WORK PHONE CELL

Transcription

1 Date Received Membership Committee Date to be voted on Voted in..? Yes or No Membership Application TO APPLY FOR MEMBERSHIP, YOU MUST BE A RESIDENT OF FREDERICK COUNTY MARYLAND AND BE WILLING TO SUBMIT TO A CRIMINAL BACKGROUND CHECK. FILL OUT THIS APPLICATION. SUBMIT CHECK OR MONEY ORDER NO CASH TO: COMPANY SECRETARY C/ O UNITED FIRE COMPANY 79 SOUTH MARKET STREET, FREDERICK, MD TYPE OF MEMBERSHIP: Check one MEMBERSHIP FEE ($10.00) Regular Membership Only REGULAR Membership $10.00 HONORARY Membership $ 0.00 BACKGROUND CHECK (An additional fee may be charged, if applicable) TOTAL ENCLOSED Make check or Money order to UNITED FIRE COMPANY NAME SOCIAL SECURITY NUMBER DATE OF BIRTH First Middle Last ADDRESS CITY COUNTY STATE ZIP HOME PHONE WORK PHONE CELL EQUAL MEMBERSHIP OPPORTUNITY: It is the policy of United Steam Engine No. 3 Inc. to select new applicants and to promote current members based on qaulifications, with out regard to race, religion, color, national orgin, sex, material status, sexual orientation, age or disability. Each applicant must meet membership requirements. Such requirements may include successful completion of an oral interview, background investigation, as well as submission of certain documents. CERTIFICATION AND AUTHORIZATION: I hereby certify that the statements contained herein are true and correct to the best of my knowledge. I understand that should an investigation disclose misrepresentation, omissions or falsifications, my application may be rejected, or if I am a member, my rights and privileges of membership may be immediately terminated. My signature indicates that I understand that a job of a firefighter or EMT provider is physically challenging and my membership as an Apprentice or Operational member is dependent upon successful completion of a medical examination, as well as successful completion of minimum training requirements. Administrative and Social membership do not require a medical evaluation. I authorize United Steam Fire Company No. 3 Inc. to perform a criminal background investigation and to investigate all statements contained herein, and direct the custodian of any records relevant to the confirmation of these to release such information for verification. Signature of Applicant Date Signature of Parent/ Guardian (for applicants under 18 years of age) Date

2 PERSONAL INFORMATION Nickname/ preferred name Are you over 18 years old Yes No Driver s License # State Class/ Type In case of emergency notify Name Phone # Relationship Address City State ZIP Are you are citizen of the United States Yes No If no, do you have a legal right to remain permanently in the United States Yes No Have you ever been convicted of any crime? Yes No. If yes explain EMPLOYMENT INFORMATION Employer Name Address Supervisor s name Phone Dates of Employment From To Job Title Job Description EDUCATION Circle Highest grade completed Do you have a high Scholl Diploma or a GED Yes No If Yes year received Last high school attended Address City State ZIP Colleges or trade school attended Name City / State Type of diploma/ degree Field of Study Dates Attended

3 PREVIOUS FIRE DEPERTMENT AFFILIATIONS Please list previous or current fire department memberships 1. Reason for Leaving 2. Reason for Leaving 3. Reason for Leaving REFERENCES List three (3) references NOT related to you. One reference must be a current member of United Fire Steam Engine Company No.3 Inc. 1. Name Address Phone 2. Name Address Phone 3. Name Address Phone Voluntary Information The following information is for statistical purposes only. EEO Race Category Caucasian Black/ African American Asian or Pacific Islander Hispanic American Indian, Eskimo Other Sex Male Female

4 FOR INTERNAL USE ONLY Oral Interview date Conducted by Background check completed Yes No Pass Fail Reference check completed by Recommend for Membership? Yes No

5 Information for Applicants Application Process: Submit a completed membership application. Complete an applicant interview with one or more members of the Membership Committee. Produce a clean criminal background history check. Be accepted into membership at a regular general membership meeting. Attend a Company Orientation. Time Commitment: Attend and participate in Company meetings and functions. Attend and participate in Company fundraising activities. Attend and participate in Company public education activities. Operational members are expected to participate in station standby activities in order to maintain knowledge and proficiency to respond to emergency calls. Operational members are expected to attend regular company-level drills and all mandatory training. Duties and Responsibilities: Familiarize yourself with Department rules and regulations. Familiarize yourself with the Department s Mission Statement and Code of Ethics. Conduct yourself in a professional manner in all encounters with the public, on or off duty. Requirements for Operational Members: Successfully complete a Frederick County Medical Physical Evaluation conducted free of charge by the County s contract medical provider (CorpOHS). Must complete the Frederick County Orientation Program, unless otherwise waived by the Training Officer. Complete mandatory training in accordance with United Steam Fire Engine Company No. 3 and Frederick County policies and procedures. Maintain a minimum proficiency and activity level defined by United Steam Fire Engine Company No. 3 policies and procedures. Maintain yourself in good health and ready to respond to emergency calls in accordance with Frederick County medical physical standards.