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.

Vaccine Card (optional past Nov 1)

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.

Please Read Carefully Before Signing the Authorization

DISCLOSURE

In considering you for employment and, if you are employed, in considering you for subsequent promotion, assignment, reassignment, retention, or discipline, Gerrittsen Beach Fire Deparment (“the Company”) may request and rely upon one or more consumer reports, investigative consumer reports or criminal background reports about you that we obtain from a consumer reporting agency, such as IntelliCorp Records, Inc.

IntelliCorp Records, Inc. can be contacted by mail at 3000 Auburn Dr, Suite 410; Beachwood, OH 44122; or phone: 1-888-946-8355; or website: www.intellicorp.net.

For explanation purposes:
a “consumer report” is a written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. Such information may include, for example, credit information, criminal history reports, or driving records; and an “investigative consumer report” is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information. In the event an investigative consumer report is requested about you, you are entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act (“FCRA”).

Under the FCRA, before the Company can obtain a consumer report or investigative consumer report about you for employment purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

AUTHORIZATION

This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application.

I have read and understand the foregoing Disclosure, and authorize the Gerrittsen Beach Fire Department to obtain and rely upon consumer reports or investigative consumer or criminal reports concerning me. By my signature below, I authorize the Gerrittsen Beach Fire Department to obtain any such reports and to share the information received with any person involved in their decision about me. *

I DO authorize you to contact my current and/or previous employer(s) for Employment and Reference Verifications

I DO NOT authorize you to contact my current and/or previous employer(s) for Employment and Reference Verifications

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

I also agree that this Disclosure and Authorization in electronic (including electronically signed) form will be valid for any consumer reports, criminal or investigative consumer reports that may be requested about me.

I have the right to make a request to the Gerrittsen Beach Fire Department & IntelliCorp Records, Inc, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which the Gerrittsen Beach Fire Department & IntelliCorp Records, Inc has previously furnished within the two year period preceding my request.

I certify that all elements of the personal data I have provided are true, accurate and complete. I understand and agree that any omission, false statement, misleading statement, or answer made by me will be sufficient grounds for rejection or discharge. *

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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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