Membership Application

Membership Application

Chopmist Hill Fire Department
Type of Membership
Applicants age 14-17 should select Limited Privilege Membership. Applicants 18+ should select Regular Membership.
Personal Information:
Full Name

First NameMiddle NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone Number
Format: (000) 000-0000.
Cell Phone Service Provider
T-Mobile, Verizon, AT&T, First Net, Etc.
Birth Date

MonthDayYear
E-mail
example@example.com
Social Security Number
Drivers License Number
Drivers License State
License Class/Endorsements
Have you ever been convicted of a crime? If yes, please explain:
Emergency Contact:
Name
Name of Reference
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Previous Experience
Have you ever been a member of a Fire Department, Rescue Service, or similar Organization? If yes, please answer questions listed below.
Organization Name
Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Reason for Leaving
Certifications/Licenses (Ex. Hazmat, NFPA 1001-Firefighter 1, CPR, EMT, Etc.)
List any relevant certifications and/or licenses held along with any applicable license numbers.

Send Application:
A BCI check is required for all applicants over the age of 18. BCI checks are to be provided by the applicant and may be obtained at the Rhode Island Attorney General's Office or at the Scituate Police Department. The BCI can be attached below and submitted with this application or turned in after. Applications for membership WILL NOT be read/accepted until a BCI is provided.
Please attach BCI here…

Cancelof
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature

Required for Junior/Limited Privilege Membershio Applications.
Should be Empty:

Previous Experience