Volunteer Fire Department Application

DURHAM FIRE AND RESCUE 615 HALLOWELL RD DURHAM, MAINE 04222

207-353-2473

APPLICATION FOR MEMBERSHIP

WHICH SERVICE ARE YOU APPLYING FOR:
FIRE,   RESCUE,     ENGINEER,     FIRE POLICE,                EXPLORERS

NAME____________________________________________________________
       (last)              (first)             (middle initial)

ADDRESS__________________________________________________________

(street)

__________________________________________________________
   (city)                    (state)          (zip code)

S.S.# ____/____/_____ D.O.B. ____/____/____ Drivers Lic #_____/___________ (state) (number)

TELEPHONE # (work)_____________ (home)_____________ (cell)_____________ Would you like to receive text pages? YES, NO, IF YES, Carrier? ______________

EMAIL ADDRESS:_____________________________________________________

ARE YOU AVAILABLE________ (weekdays) ________ (nights) _______(weekends)

Highest Grade Completed (circle) 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16

High School: ____________________________________D.O.G._______________

College/Technical:____________________________________________________

Course/Major:__________________________ Diploma/Degree:______________

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List all prior Fire or Rescue training you’ve had, licenses held or currently holding, and any other pertinent certificates. (Copies may be requested for records) __________________________________________________________________ ___________________________________________________________________

Are you presently employed _________          # years with current employer______

Employers Name_____________________________________________________

Employers Address___________________________________________________

Employers Telephone # ______________ Supervisors Name _________________

May we contact your employer?________________________________________

Do you have any physical limitations that would prevent you from performing the duties of the job you are applying for? Yes_____ No_____ If Yes, please explain:

Previous injuries, list types and dates?____________________________________

Have you ever been convicted of a crime? Yes_____ No_____ If yes, please explain:____________________________________________________________

Have you ever been convicted of reckless driving, OUI, or driving to endanger? Yes_____ No_____ If yes, please explain:________________________________

Why do you want to become a member?_________________________________

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Please list three references (non-relatives) Names and Telephone #

Name_______________________________________Telephone #_____________

Name_______________________________________Telephone #_____________

Name_______________________________________Telephone #_____________

I certify that the answers I have given are complete and truthful to the best of my knowledge. I understand that I may be terminated if any of the above information I have given is false. I authorize my employer to release any information regarding my employment to Durham Fire and rescue. I also authorize Durham Fire and Rescue to check into my driving record, do a criminal background check, and contact the individuals I have listed as references and request information from my employer.

Signature_____________________________________________ Date__________

Date Reviewed _______________ By whom______________________________

Date Interviewed_________________ By whom___________________________

Date Application Approved____________ By whom________________________

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