EmailMe Form - Gerrittsen Beach Volunteer Fire Department

Type of Membership *

Firefighter

Emergency Medical Technician

Dispatcher

Driver

Junior Firefighter (Under 18 Older than 16)

Auxillary (Gerritsen Beach Residents Only)

Why are you asking to join the Gerrittsen Beach Fire Department? *

Personal Data

Name *

First Middle Last Suffix

Social Security Number *

123-45-678

Other or Maiden Name

First Middle Last Suffix

Date Of Birth (MM/DD/YYY) *

Height *

5' 11"

Place of Birth *

City, County, State or Country

Address *

Street Address City State / Province / Region Postal / Zip Code

Previous address (if less than Seven Years:)

Street Address City State / Province / Region Postal / Zip Code

Phone Number *

### - ### - ####

Email *

Cell Service (AT&T, Verizion, Boost, Cricket, ETC) *

Needed for department event notification systems

Do you have a valid N.Y.S. Drivers License? *

Yes

No

License Number or Non-Driver ID Number *

Are you currently an active: CFR, EMT-B, AEMT-I, AEMT-CC, AEMT-P? *

Yes

No

NYS DOH License Number

Were you ever a: CFR, EMT-B, AEMT-I, AEMT-CC, AEMT-P? *

Yes

No

Has your drivers licence ever been suspended or revoked? *

Yes

No

If yes, you will be asked to explain on interview.

If you have a resume, please upload.

Emergency Contact Information

Emergency Contact Person *

Emergency Contact Phone Number *

### - ### - ####

Employment

Current Employeer *

If none put "Unemployed" If Student put "Student"

Current Employer Address *

Street Address City State / Province / Region Postal / Zip Code

Previous Employeer *

If none, put "Unemployeed"

Previous Employer Address *

Street Address City State / Province / Region Postal / Zip Code

Personal References

Reference 1 Phone *

### - ### - ####

Reference 1 Name *

First Last

Describe your relationship to Reference 1 *

Years Known, etc

Reference 2 Name *

First Last

Reference 2 Phone *

### - ### - ####

Describe your relationship to Reference 2 *

Years Known, etc

Background

Have you ever applied to or been a member of any Volunteer Fire Department or Ambulance Service? *

Yes

No

If Yes, Name of Department

Have you ever been convicted of a crime? or CURRENTLY charged with a crime. *

Yes

No

If YES you will be asked to explain and provide final dispositions. A criminal conviction will not necessarily result in disqualification. Rather, such factors as any relationship to the job, your age at the time of the conviction, the length of time since the conviction, the seriousness and nature of the crime, and any rehabilitation will be considered.

DISCLOSURE AND AUTHORIZATION FORM TO OBTAIN CONSUMER REPORTS AND CRIMINAL REPORTS FOR VOLUNTEER & EMPLOYMENT PURPOSES

New York State Executive Law §837 requires applicants for membership to volunteer fire departments to undergo a criminal history check through the Division of Criminal Justice Services (DCJS) to determine if they stand convicted of the crime of arson or sex offense in New York State. This law applies to new applicants, transfers from other fire companies and reinstatements to membership.

Under Article 25 Section 380-g of the New York General Business Law, if an employer receives a consumer report containing criminal conviction information, the employer must provide the applicant or employee who is the subject of the report, a printed or electronic copy of Article 23-A of the New York Correction Law, which governs the employment of persons previously convicted of one or more criminal offenses. *

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Gerrittsen Beach Certification

I hereby certify that I am eighteen years of age or older (16 1/2 for Youth Applicants), that I am not addicted to drugs or alcohol and that I am joining the Gerrittsen Beach Fire Department with the understanding that it is an orgization designed to furnish the fire protection, emergency medical services, and related activites to the community of Gerritsen Beach. That when becoming a member, I voluntarily consent to assist the Department in all of its activities, as outlined in the Departments by-laws, rules and regulations in a willing and cooperative manner.

I further certify that all the facts ser forth in this application are true, complete, and correct to the best of my knowledge and belief. I understand that statements and information shall be subject to investigation and that false and/or misleading statements shell be grounds for denial of membership and or dismissal from the Gerritsen Beach Fire Department and a notification will be made to the Volunteer Firemens Association of the City of New York

I hereby understand that as a member you respond to emergency incidents; drive and operate apparatus and assists in the suppression of fires, conduct rescues, entry, ventilation, salvage and overhaul work and administers EMS care to patients; respond to rescue calls and administer proper emergency medical aid; respond to hazardous materials incidents and executes appropriate mitigation measures; assist with and conduct fire prevention inspections within fire districts as directed; conduct public safety programs; administer EMS skills to patients as prescribed by protocol; and perform emergency activities in the mitigation of hazardous materials incidents. *

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