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Barnegat Fire Company No. 1
Membership Application Packet
Personal Information
Applying For
*
Please select
Fire fighter
Fire Police
Auxiliary
Name
*
First
Middle
Last
Suffix
Date of Birth
*
MM/DD/Year
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Mobile Phone
*
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Home Phone
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Social Security
*
Email
*
Driver's License #
If not Licensed, please enter "N/A"
Issuing State
Please select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
If applicable, please upload a copy of your driver's license.
Have you ever been in an Accident?
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Yes
No
If yes, please explain
Have you ever been convicted of a crime?
*
Yes
No
If yes, please explain
Would you have any difficulty or concerns performing the physical activities typically associated with Firefighting?
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Yes
No
If yes, please explain
Firefighting Experience and Training
Are you now, or have you previously been a member of a Volunteer Fire or EMS company?
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Yes
No
If yes, please List the Department below.
Company/ Department, City/State, Length Of service.
Are you Currently, or have you previously been a member of a Career Fire Department?
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Yes
No
If yes, please List the Department below.
Company/ Department, City/State, Length Of service.
Who can we speak to in that organization about your experience?
Name, Rank, and Phone #
Have you ever applied for membership with the Barnegat Fire Company No. 1?
*
Yes
No
Are you a certified firefighter?
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Yes
No
Do you have any of the following Firefighter certifications listed below:
Firefighter 1
Firefighter 2
Hazmat Awareness
Hazmat Ops
ICS 100
ICS 200
ICS 700
ICS 800
Current FIT test
If you have checked any of the certifications above please upload a copy.
Employment History
Current Employer
*
If not employed, please enter "NOT EMPLOYED"
Current Position
Employer's Phone #
Employer's Address
Street Address/City/State/Zip
Military Service
Have you ever been in the Military?
*
Yes
No
If Yes List Branch/ Date of Service/ Rank and Discharge Status
References
List any members of the Barnegat Fire Company with whom you are acquainted with?
Name and Phone #
List three (3) references, other than relatives and others named above.
*
Name, Relationship and Phone #
Emergency Contact Information
Emergency Contact Name
*
Emergency Contact Address
*
Emergency Contact Phone
*
Why do you want to become a member of the Barnegat Fire Company ?
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I hereby attest that all of the above information is true to the best of my knowledge and agree to any personal screening of my background through local, state, and federal authorities. I authorize the Barnegat Fire Company to complete this background investigation. I understand that if any of the above information is found to be false, my application will be disqualified and terminated immediately.
*
Yes
No
