Dear Applicant,

Thank you for your interest in the Funkstown Volunteer Fire Company, Inc. We look forward to meeting you and helping you prepare for membership within the company. Our goal is to make this process go as quickly as possible.

We need all the following mailed or dropped off at the above address:

1.      Application filled out completely and signed.

2.      Three references sheets filled out completely and signed

3.      $5.00 application fee.

Please bring with you to your interview:

1. All training pocket cards
2. Certificates
3. Hep B Vacc. Card ( if you have one)

If you have any questions or concerns, please call the station and ask for a Investigation committee member.

Membership Application

Full Name: ______________________________________________________

Mailing Address: __________________________________________________

City, State, Zip: ___________________________________________________

Phone #: (Home) ___________________ (cell) ___________________

(Pager) ____________________ (Work) _____________________

Social Security #: _ _ _-_ _-_ _ _ _             Date of Birth ____ / ____ / ____

Interests:

Fire_______ EMS______ Fundraiser/Bingo_____

Education:

High School________________________________________________

College____________________________________________________

Other_____________________________________________________

List any current or previous Fire, EMS, Rescue Companies memberships or employment and number of years of service:

Have you ever been convicted of any crimes? If so please explain.

Current Employment:

Training:

FF1____ FF2____ EMT-B____ CPR____ Haz-Mat_____

Other: _______________________________________________________________

Are you willing to get a physical?

Yes_____ No_____

Are you willing to take an alcohol and drug test?

Yes____ No_____

Will you allow the company to do a criminal background check, including but not limited to driving records?

Yes____ No_____

Give a brief statement in your own handwriting explaining what your goals and expectations are regarding membership with this department:

Application agreement:  I agree to abide by the rules, regulations, and the Funkstown Volunteer Fire Company Inc. by-laws set fourth by this company. I also understand any misrepresentation of omission of facts made on this application shall be considered as cause for dismissal or refusal into the organization.

Signature____________________________________ Date___________

Parents (if under 18)___________________________ Date___________

Reference Sheet

APPLICANT’S NAME:        ________________________________________________

REFERENCE’S NAME:      ________________________________________________

REFERENCES PHONENUMBER:            ____________________________________

QUESTIONS:

1. HOW DO YOU KNOW THE APPLICANT?

2. HOW LONG HAVE YOU KNOWN THE APPLICANT?

3. WOULD YOU RECOMMEND THE APPLICANT FOR MEMBERSHIP IN A FIRE OR EMS COMPANY?

4. USING A SCALE OF ONE (1) TO FIVE  (5), ONE BEING THE LOWEST, RATE THE APPLICANT’S FOLLOWING QUALITIES?

ANY ADDITIONAL INFORMATION WE NEED TO KNOW ABOUT THE APPLICANT, PLEASE LIST IN THE BACK.

SIGNATURE: ______________________________ DATE: ___________

Reference Sheet

APPLICANT’S NAME:        ________________________________________________

REFERENCE’S NAME:      ________________________________________________

REFERENCES PHONENUMBER:            ____________________________________

QUESTIONS:

5. HOW DO YOU KNOW THE APPLICANT?

6. HOW LONG HAVE YOU KNOWN THE APPLICANT?

7. WOULD YOU RECOMMEND THE APPLICANT FOR MEMBERSHIP IN A FIRE OR EMS COMPANY?

8. USING A SCALE OF ONE (1) TO FIVE  (5), ONE BEING THE LOWEST, RATE THE APPLICANT’S FOLLOWING QUALITIES?

ANY ADDITIONAL INFORMATION WE NEED TO KNOW ABOUT THE APPLICANT, PLEASE LIST IN THE BACK.

SIGNATURE: ______________________________ DATE: ___________

Reference Sheet

APPLICANT’S NAME:        ________________________________________________

REFERENCE’S NAME:      ________________________________________________

REFERENCES PHONENUMBER:            ____________________________________

QUESTIONS:

9. HOW DO YOU KNOW THE APPLICANT?

10. HOW LONG HAVE YOU KNOWN THE APPLICANT?

11. WOULD YOU RECOMMEND THE APPLICANT FOR MEMBERSHIP IN A FIRE OR EMS COMPANY?

12. USING A SCALE OF ONE (1) TO FIVE  (5), ONE BEING THE LOWEST, RATE THE APPLICANT’S FOLLOWING QUALITIES?

ANY ADDITIONAL INFORMATION WE NEED TO KNOW ABOUT THE APPLICANT, PLEASE LIST IN THE BACK.

SIGNATURE: ______________________________ DATE: ___________