Application For Membership

Sharpsburg. North Carolina 27878
Name
Today's Date

MonthDayYear
Date
Address
Social Security Number
NC Driver's License No.
Telephone: (Home)
(Work)
Employer
Hours normally worked
1. List each state/county you have lived in within the past ten(10) years
2. List any criminal convictions
3. List any traffic convictions in the past seven years
4. Are there special circumstances related to convictions listed in questions 2 and 3 above which you would like us to consider? (NOTE criminal and traffic convictions will be considered on case by case basis and do not automatically disqualify you for membership)
5. List any previous relevant experience or training
6. Please explain in your own words the main reason for wanting to become a member
I hereby certify that there are no willful misrepresentations or falsifications of my statements and answers to listed questions. I am aware that, should an investigation disclose such misrepresentation or falsification, my application will be rejected. I do hereby certify that if accepted as a member of the Sharpsburg Fire Prevention Association, Inc. I will abide by the By-Laws of the Association and any other Policies and Regulations of the Department.
Signature

Clear
Date

MonthDayYear
Date
Criminal Record from all Counties/States where you have resided in the past ten (10) years. Driving Record from all Counties/States where you have resided in the past seven (7) years. At least one personal letter of reference.
AUTHORIZATION FOR RELEASE OF RECORDS
. do hereby authorize any military organization, law enforcement agency. physician or other medical personnel, insurance agencies, banks and credit agencies, former and present employers, or other individuals to furnish to the Sharpsburg Fire Prevention Association (the "Department") or its authorized agent all available information. I hereby release any of the above from any and all civil or criminal liability whatsoever for providing this information.
Signature

Clear
Date

MonthDayYear
Date
Witness
Date

MonthDayYear
Date
SS#
NCDL#
Date of Birth
Authorization for Consumer Report

I understand and acknowledge that I am applying for membership with the Sharpsburg Fire Prevention Association (the "Department" In connection with that application, I expressly authorize the Department to conduct a full background check and to obtain a Consumer Report and/or an investigative report about me, including but not limited to, a criminal records check and/or credit report. I further understand and acknowledge that if I am accepted as a member, this authorization shall remain on file and shall serve as an on-going authorization for the Department to obtain such reports at any time during my membership. I acknowledge that I have received a copy of the attached "Fair Credit Reporting Act Disclosure" and "a Summary of Your Rights Under the Fair Credit Reporting Act" prior to executing this authorization.
Signature

Clear
Printed Name
Date

MonthDayYear
Date
SS#
NCDL#
1st Reading
Date of Birth
Accepted
2nd Reading
Rejected
Date

MonthDayYear
Date
Secretary
Six month probation period end date

MonthDayYear
Date
Accepted
Rejected
Should be Empty:

AUTHORIZATION FOR RELEASE OF RECORDS