Moyers Corners Fire Department, Inc. Explorer Post 209

Membership Application

 

Applicant must be 14 years of age or a graduate of eighth grade.

Please print or type.

 

PART ONE

NAME: ___________________________________________________ Date: _______________

                        LAST                                       FIRST                                      M.I.

ADDRESS: __________________________________________________APT. # ____________

APT. COMPLEX NAME: ________________________________________________________

CITY: _______________________ ZIP: __________________ PHONE: ___________________

AGE: _________ DATE OF BIRTH: ____________ PLACE OF BIRTH: __________________

SOCIAL SECURITY NUMBER: _____________________________________

NEW YORK STATE DRIVER’S LICENSE (learner’s permit): #________________________

CLASS: ____________________ EXP. DATE: _____________________

Please attach a copy of your driver’s license / learner’s permit if applicable.

 

HAVE YOU EVER BEEN CONVICTED OF A CRIME (MISDEMEANOR OR FELONY)

OTHER THAN A PARKING VIOLATION?  ÿ YES   ÿ NO

TRAFFIC VIOLATION (S)? ÿ YES  ÿ NO

IF YES, LIST DATE AND TYPE OF CONVICTION: __________________________________

______________________________________________________________________________

______________________________________________________________________________

 

PART TWO

PART TWO: EMPLOYMENT

NAME OF EMPLOYER: _________________________________________________________

EMPLOYER ADDRESS: _________________________________________________________

BUSINESS PHONE #: _________________ HOURS OF EMPLOYMENT: ________________

HOW LONG HAVE YOU BEEN EMPLOYED BY THIS FIRM? __________________

 

PART THREE

PART THREE: MEMBERSHIP

I WISH TO BE CONSIDERED FOR MEMBERSHIP IN MOYERS CORNERS FIRE DEPARTMENT, INC. EXPLORER POST 209.

 

HAVE YOU PREVIOUSLY APPLIED FOR MEMBERSHIP IN EXPLORER POST 209? _______ IF YOU WERE ACCEPTED, AND ARE NO LONGER A MEMBER, PLEASE STATE REASON FOR TERMINATING MEMBERSHIP AND DATE: ______________________________________________________________________________

 

 

PART FOUR

PART FOUR: PREVIOUS EXPERIENCE

LIST BELOW ANY PREVIOUS EXPERIENCE RELATED TO FIREFIGHTING, INCLUDE NAME AND ADDRESS OF ANY PRIOR ORGANIZATION, LENGTH OF SERVICE AND REASON FOR LEAVING, (ATTACH ADDITIONAL SHEETS IF NECESSARY)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PLEASE LIST A REFERENCE FROM EACH ABOVE DEPARTMENT / ORGANIZATION, INCLUDE NAME, ADDRESS, PHONE AND TITLE/POSITIONS HELD:

______________________________________________________________________________

______________________________________________________________________________

 

PART FIVE

PART FIVE: EDUCATION

ARE YOU CURRENTLY ENROLLED IN SCHOOL?  ÿ YES            ÿ NO

IF YES, WHAT SCHOOL? NAME: ________________________________________________

ADDRESS: ________________________________ HIGHEST GRADE COMPLETED: ______

IF IN COLLEGE, WHAT IS YOUR COURSE OF STUDY? _____________________________

LIST BELOW ANY FIRE SCHOOLS, MEDICAL COURSES, AND CERTIFICATIONS WHICH YOU HAVE COMPLETED SUCCESFULLY AND ARE CURRENTLY CERTIFIED IN, (Please be as specific as possible and include where the course was taken, the approximate dates, and the state registry number if applicable.)

FIRE COURSES: ­_______________________________________________________________

OTHERS: _____________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

E.M.S. COURSES: EMT LEVEL: _______________ CARD NUMBER: ___________________

PLACE TAKEN: _____________________________ EXPIRATION DATE: _______________

CPR: _______________________________________ EXPIRATION DATE: _______________

OTHERS: _____________________________________________________________________

NOTE: PLEASE ATTACH COPIES OF APPLICABLE CERTIFICATES

 

PART SIX

PART SIX: EMERGENCY NOTIFICATION

WHO SHOULD WE NOTIFY IN THE EVENT OF AN EMERGENCY?

NAME: _______________________________________ DAY PHONE: ___________________

RELATIONSHIP: _______________________________ NIGHT PHONE: _________________

ADDRESS: ____________________________________________________________________

SHOULD WE NOTIFY THIS PERSON IN THE EVENT OF A MINOR INJURY? __________

If you have an up to date physical, please attach a copy of it to this application.

 

PART SEVEN

PLEASE READ, SIGN, AND DATE THE BELOW AGREEMENT BEFORE TURNING THIS APPLICATION IN.  PLEASE TURN THIS APPLICATION TO WHOMEVER YOU ARE TOLD TO WHEN IT IS GIVEN TO YOU.

 

I UNDERSTAND THAT ANY FALSE ANSWER, STATEMENT, IMPLICATION, OF THE OMISSION OF ANY PERTINENT OR REQUIRED INFORMATION MADE BY ME ON THIS APPLICATION OR OTHER REQUIRED DOCUMENTS SHALL BE CONSIDERED SUFFICIENT CAUSE FOR DENIAL OF MEMBERSHIP OR REMOVAL FROM THE ACTIVE ROSTER OF THIS DEPARTMENT.  I ALSO UNDERSTAND THAT ALL EQUIPMENT ISSUED TO ME SHALL REMAIN PROPERTY OF THE MOYERS CORNERS FIRE DEPARTMENT EXPLORER POST AND MUST BE SURRENDERED UPON TERMINATION OF MEMBERSHIP.

 

THIS CERTIFIES THAT THIS APPLICATION WAS COMPLETED BY ME, AND THAT ALL ENTRIES ON IT AND INFORMATION IN IT ARE COMPLETE TO THE BEST OF MY KNOWLEDGE.

 

SIGNED: ______________________________________________ DATE: _________________

 

THE MOYERS CORNERS FIRE DEPARTMENT EXPLORER POST 209 DOES NOT DISCRIMINATE BECAUSE OF RACE, CREED, COLOR, RELIGION, NATIONAL ORIGIN, SEX, OR DISABILITY.

 

 

 

Please fill out neatly, and send the above application to:

 

Moyers Corners Fire Department

Attn. Explorer Post 209

7697 Morgan Road

Liverpool, NY 13090

 

 

 

This Page Maintained By: Jeffrey Newton, Firefighter & Explorer Advisor.