EmailMe Form - Gerrittsen Beach Volunteer Fire Department

Name *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone Number *

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

Email

Emergency Contact Person *

Phone Number *

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

Type of Membership *

Dispatcher

Emergency Medical Technician

Firefighter

Special Services

Youth (under 18)

You must live or work in the immediate Gerritsen Beach area to become an EMT or Firefighter.

There are NO Paid Positions, this is a volunteer department.

Special Service: Special skills that you are willing to help

Brief Employment Record

Position, start/end date, name and phone number of employer

Military Service Record

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

Yes

No

If Yes and if applying for a Firefighter or EMT position you are required to provide certified NYS driving abstract.

Has your drivers licence ever been suspended or revoked?

Yes

No

If Yes, please explain

Have you ever been convicted of a crime? *

Yes

No

If yes, please explain

Date, Type, Disposition

Previous related experience & special talents

Anything including but not limited to: EMS, Fire, Auto/DieselMechanic, Carpentry, Electrical, Electronics, Plumbing, Accounting, Computers, Clerical, Fund Raising.

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. *

Yes

No