2022 BVFD Membership Application

Burtonsville Volunteer Fire Department

APPLICATION FOR MEMBERSHIP
Before moving forward, please read the following thoroughly and check to accept them. Applications without all of these boxes checked will be denied.*

I understand that this is a volunteer opportunity only and is NOT a paid position or employment.I understand that I will be required to complete and pass a county physical/medical exam and State and Federal Criminal background investigation.I understand that the first year of membership is a probationary period, during which I am required to complete more that 160 hours of formal training (if I come in with no previous certifications) in online and classroom courses to attain the level of minimum staffing. All training and gear will be provided free of charge, but I will need to provide my own online access and transportation to local training facilities.I understand that in addition to the above training time, I will be required to perform one 12-hour duty shift per week (from 7pm-7am any night, or 7am-7pm Saturday or Sunday) (or four 12-hour duty shifts per week as a Live-in Member) for the duration of my membership with the Department.I understand I am expected to commit to at volunteer period of at least 3 years.I agree to respond to BVFD communications as requested, including timely notices of duty shifts and completion of ongoing required certifications by the specific deadline.
Check Type of Membership Requested Below

FIREEMSASSOCIATEAUXILIARY
Personal Data
Check here if you are between the age of 16-18
Last*
First*
Middle
Cell Phone Number*
Home Phone Number
Work Phone Number
Address
Street
Apt.
City
State
Zip
Email*
example@example.com
Name of BVFD Member Who Recruited Applicant
Names of Friends/Family Members Who Are BVFD Members
Employment

Start with most recent job
Current or Most Recent Employer*
Complete Address*
Month/Year Employment Started
Month/Year Employment Ended
Reason For Leaving (Enter N/A if Not Applicable)
Your Title/Position/Job
Name & Title of Supervisor*
Phone Number*
Please enter a valid phone number.
PREVIOUS EMPLOYER
Prior Employer
Month/Year Employment Started
Month/Year Employment Ended
Complete Address
Reason For Leaving (Enter N/A if Not Applicable)
Your Title/Position/Job
Name & Title of Supervisor
Contact Phone Number
Please enter a valid phone number.
PREVIOUS EMPLOYER
Prior Employer
Month/Year Employment Started
Month/Year Employment Ended
Complete Address
Reason For Leaving (Enter N/A if Not Applicable)
Your Title/Position/Job
Name & Title of Supervisor
Telephone Number
Section Three: References

Complete Info required, DO NOT LIST RELATIVES
Reference #1
Name of Person Who Has Known You For Two or More Yrs.*
Occupation
Number of Years Known*
Complete Mailing Address
Daytime Phone #
Email Address*
example@example.com
Reference #2
Name of Person Who Has Known You For Two or More Yrs.*
Occupation
Number of Years Known*
Complete Mailing Address
Daytime Phone #
Email Address*
example@example.com
Reference #3
Name of Person Who Has Known You For Two or More Yrs.*
Occupation
Number of Years Known*
Complete Mailing Address
Daytime Phone #
Email Address*
example@example.com
Section 4: Education & Training
Name of High School Attended*
Year of Graduation / GED*
Name of College/University Attended
Degree/Number of Credits
Business or Vocational Schools Attended
Section Five: Fire/Rescue/EMS Experience
Current/Previous Fire Rescue EMS Department Affiliation
Membership Dates

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Complete Address of Fire Rescue EMS Department (enter N/A if not applicable)
List Ranks Held By You, As Well As Relevant Training (ie: Basic Fire Fighting, EMT, etc.) Attach Copies of Certificates
Your Current Status With The Organization or Reason For Leaving

Place an "X" in the appropriate box. (If you answer "yes" to any question, please explain below*

	Yes	No
Have you ever been convicted as an adult, of a criminal offense?
Have you ever applied for Membership in the Burtonsville VFD?
Have you ever applied, or been turned down for Membership at any other Fire/Rescue/EMS Department?

Please explain any Yes answers in the grid above
Describe Why You Are Interested In Membership [and] Any Other Comments
SECTION SEVEN: CERTIFICATION AND AUTHORIZATION

certify that have read and that I fully understand this application also certify that all of the information is true and complete to the best of my knowledge.

By signing this application, am authorizing the Burtonsville Volunteer Fire Department, through its duly authorized representatives, to conduct a thorough and comprehensive background investigation of my personal life and work history, in order to determine my suitability for membership. By signing this application am granting the B.V.F.D. access to all records and authorize the release of all information held by any individual or organization By signing this application, 1am acknowledging that I understand that should any information given on, or as a result of this application, be false, misleading or erroneous, it may result in the rejection of my application for membership, or in my discharge from the B.V.F.D. agree and understand that if this application is submitted online or electronically. my type-printed name on the signature line is legally binding, and is equal to my handwritten original signature. Thave reviewed the requirements of membership and I understand that the duties are physically challenging and that my membership will be dependent upon my successful completion of a physical (medical) exam and a drug screening. to be conducted by Montgomery County. also understand that as a part of the application process - will be required to be fingerprinted

I agree to abide by all Bylaws, Policies and Procedures, Regulations and other directives of the Burtonsville Volunteer Fire Department, as well as all relevant laws, rules and regulations of the Montgomery County Government. I agree to assist, to the best of my ability, in the voluntary work necessary for the operation and maintenance of the Burtonsville Volunteer Fire Department, Incorporated

Junderstand that my Social Security Number could help to expediate the processing of my application and provide it voluntarily. I also understand that my SSN and Date of Birth is not required by this application.
Signature of Applicant*

Clear
Social Security Number (Optional)
Date of Birth*

MonthDayYear
Date
Date*

MonthDayYear
Date
SSN Date of Birth (Optional) Parental Authorization is Required for Any Applicant Under the Age of 18.
Signature of Parent/Legal Guardian
Date

MonthDayYear
Date
Signature of Witness

Clear
Should be Empty:

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Personal Data

Employment

Section Three: References

Section 4: Education & Training

Section Five: Fire/Rescue/EMS Experience