EmailMeForm
Gerrittsen Beach Volunteer Fire Department
Application has to be filled out in it's entirety.
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Type of Membership
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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?
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Personal Data
Name
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First
Middle
Last
Suffix
Social Security Number
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123-45-678
Other or Maiden Name
First
Middle
Last
Suffix
Date Of Birth (MM/DD/YYY)
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Height
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5' 11"
Place of Birth
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City, County, State or Country
Address
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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
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Email
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Cell Service (AT&T, Verizion, Boost, Cricket, ETC)
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Needed for department event notification systems
Do you have a valid N.Y.S. Drivers License?
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Yes
No
License Number or Non-Driver ID Number
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Are you currently an active: CFR, EMT-B, AEMT-I, AEMT-CC, AEMT-P?
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Yes
No
NYS DOH License Number
Were you ever a: CFR, EMT-B, AEMT-I, AEMT-CC, AEMT-P?
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Yes
No
Has your drivers licence ever been suspended or revoked?
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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
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Emergency Contact Phone Number
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Employment
Current Employeer
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If none put "Unemployed" If Student put "Student"
Current Employer Address
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Street Address
City
State / Province / Region
Postal / Zip Code
Previous Employeer
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If none, put "Unemployeed"
Previous Employer Address
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Street Address
City
State / Province / Region
Postal / Zip Code
Personal References
Reference 1 Phone
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Reference 1 Name
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First
Last
Describe your relationship to Reference 1
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Years Known, etc
Reference 2 Name
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First
Last
Reference 2 Phone
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Describe your relationship to Reference 2
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Years Known, etc
Background
Have you ever applied to or been a member of any Volunteer Fire Department or Ambulance Service?
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Yes
No
If Yes, Name of Department
Have you ever been convicted of a crime? or CURRENTLY charged with a crime.
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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.
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