West Harrison Independent Fire Company No. 1
Of The Town Of Harrison
95 Lake Street
West Harrison NY 10604-2401
914 949-0919
APPLICATION FOR MEMBERSHIP
Date___________
1. Last Name: ____________________ First Name: _______________________MI_______________
2. Address: __________________________________________________________ Apt. /Suite: _______
3. City: __________________________ State: ___________________ Zip Code: ___________________
4.Telephone Home (___) _________ Work (___)_________
5. Citizen of United States Yes____ No____ Date of birth_____/____/____
6 How long have you resided at the above address? Years: __________ Months: __________
7. How long have you resided in New York State Years_____ Months____
8. Are you 18 years of age or older? YES _____ NO _____ If No, state your age: __________
9. Do you have a New York State Drivers License? YES _____ NO _____
10.Are you currently employed Yes ___ No____?
If “yes” give employer information below
Name of Company____________________________________________________________
Address______________________________________________Telephone____________________
11. Is additional information about a change in your name or your use of an assumed name or nickname necessary to enable a check on your eligibility for membership Yes____ No____ If “Yes “ Explain?
12. OSHA regulations require that you pass a physical examination before becoming interior structural firefighters. The department’s designated Physician will provide you a free medical examination. Will you be willing to undergo a medical examination? YES _____ NO _____
13. Please indicate your availability to participate in normally required fire department activities (meetings, drills, and emergency calls).
Please check appropriate time periods.
Week Days:
Days _____ Evenings _____ Nights _____
Weekends:
Days _____ Evenings _____ Nights _____
14. Previous emergency services experience: (include only fire, police, and emergency medical service agencies).
Name of Agency:
______________________________________________________________________________
Address:
_____________________________________________________________________________________
Contact Person:
_______________________________________________________________________________
Name of Agency:
______________________________________________________________________________
Address:
_____________________________________________________________________________________
Contact Person:
_______________________________________________________________________________
(If more space is needed, Please identify on attached sheet)
15. Have you ever been a member of the United States Armed Forces? YES _____ NO _____
If the answer is “YES”, did you receive a dishonorable discharge? YES _____ NO _____
Dishonorable discharge is not an absolute bar to membership. This and other factors will affect a final membership decision.
If the above answer is “YES”, give complete details in the space provided for additional information on the last page (include service branch and service dates).
16. Have you ever been convicted of a felony or misdemeanor? YES _____ NO _____ if “YES” give details on the attached sheet.
17. Please list three personal references, other than members of this organization, family members and relatives, who have known you for at least 3 years.
• Name: ____________________________________________Tel. # ___________________________
Address: _______________________________________________________________________________
• Name: ____________________________________________Tel. # ___________________________
Address:
__________________________________________________________________________________
• Name: ____________________________________________Tel. # ___________________________
Address: _______________________________________________________________________________
18. Please list the names of any acquaintances that are members of this organization
______________________________________________________________________________________
______________________________________________________________________________________
Requirements
1 Must be between the ages of 18 and 45 years of age and of good moral character
2 Must be a resident of within the bounds of West Harrison Fire District No.1 of the Town-Village Of Harrison
3 OSHA regulations require you pass a physical examination before becoming an interior structural fighter. The West Harrison fire department’s designated physician will provide you a free medical examination.
4 Must be a probationary member for period of 1 year
5 You must attend 25 % of all alarms, meetings and attend practice committee each month by order of the chief or commanding officer.
6 You must complete all New York State required courses to become a certified interior fire fighter during the probationary period.
7 After one year the Chief shall submit a statement of your completion in writing to the department and if you have completed the requirements and have received approval of the fire Commission your name shall placed on the regular active membership rolls
8 The date of such entry to regular active membership rolls shall be designated as the date of admission
If you fail to meet any of the above requirements your application for membership shall be void
I have read and understand all of the above requirements
Signature of Applicant ___________________________________Date________
ADDITIONAL INFORMATION WITHIN THE FREEDOM OF INFORMATION LAW, ALL INFORMATION CONTAINED/OR OBTAINED HEREIN WILL REMAIN CONFIDENTIAL AND WILL BE USED ONLY FOR INTERNAL MEMBERSHIP PROCESSING
IN WITNESS WHEREOF, THIS APPLICATION HAS BEEN SUBSCRIBED THIS __________ DAY OF ___________, 2005 BY THE UNDERSIGNED APPLICANT WHO AFFIRMS THAT THE STATEMENTS MADE HEREIN ARE TRUE UNDER THE PENALTIES OF PERJURY.
APPLICANT SIGNATURE: __________________________________________________________________________
DATE: _________________________________________
WITNESSED BY:
___________________________________________________________________________________
DATE: _________________________________________
PRIVACY NOTIFICATION
Section 94 of the Public Officers Law (Personal Privacy Protection Law) requires that you be notified of the following facts when information, which will be maintained in a record system, is collected from you.
The authority to request and confirm personal information on you is found in article 6 of Executive Law.
The information will:
Be used to determine your qualifications for the position for which you are applying
Be released to the fire chief and your potential supervisor; and
Be maintained in your personnel file (if you become a fire company member) or in our Resume file for six months (if you are not a fire company member)
Failure to provide the information or authorization will result in your application not being considered for membership.
The secretary of the West Harrison Fire Department will maintain the information.
APPLICANT’S AUTHORIZATION FOR RELEASE OF INFORMATION
In order to confirm the information I supplied on my application for membership with the WEST HARRISON FIRE DEPARTMENT. I authorize all licensing agencies, education institutions, and law
Enforcement agencies, present and former employers, and the military services to disclose their relevant records about me to the WEST HARRISON FIRE DEPARTMENT whether the information be of public, private or confidential nature; and I release them from any liability and responsibility from doing so.
Last Name: _______________________________ First Name: _______________________ MI: ________
Street Address: ____________________________________________________________
City: _________________________________________ State: ________________Zip: _______________
Nickname: ____________________________________ Alias: ________________ Sex: M F
Height: _____ ft _____ in. DOB: ____/____/____ AGE: _______
Place of Birth: _________________________________
This authorization in original copy form shall be valid for this and any future information, reports or updates that may be requested.
I understand that this form will accompany requests for official documents and confirmations of my credentials.
Applicants Name: _____________________________
Signature: ______________________________________
Date__________________
Witnessed by:
Name and Title: ______________________________
Signature: ______________________________________
Date______________
Additional Information
(For Applicant)
>
>
>
