EFD Membership Form

Membership Form
Eastport Chemical Engine Company No. 1

Application for Membership
21 Union Avenue, Eastport NY 11941

631-325-0464

Instructions For Completing Application For Membership.
- Fill out application form.
- Read and sign Freedom of Information form.
- Read and sign Authorization for Release of information form.
- Read Privacy Notification.
- Read and sign Eastport Fire Districts substance abuse policy.
- The Eastport Fire District provides a service awards program. Please fill out the Designation of Beneficiary Form for this service awards program.
- The Eastport Fire District provides a life insurance policy to all Eastport Firefighters. Please fill out the Designation of Beneficiary Form for this life insurance policy.
- The Eastport Fire District provides Hepatitis B Vaccines. Please fill out the form accepting or declining this vaccine. Receiving the vaccine is not mandatory, but it is recommended.
- The Eastport Fire Department has a Benevolent Association. This association aids as needed to Eastport firefighters. If you would like to join, please fill out their application and provide a check for $15 made out to Eastport Firefighters Benevolent Association. The $15 covers the application fee and yearly membership dues.
- Please fill out Suffolk County Volunteer Recruitment Program Volunteer Profile. This form helps improve the recruiting of new firefighters.
- Provide a check for $9 made out to Eastport Fire Department for membership dues.
You will be contacted by the membership committee who will schedule a meeting with you. If approved by the membership committee the membership of the Eastport Fire Department will vote on your application prior to your next meeting. If approved, you will start on the 1st day of the month following the meeting.

Personal Information
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Mailing Address

Mailing Address Line 2

CityState / Province

Postal / Zip Code
How many years and months have you resided at the above address?*
How many years and months have you resided in New York State?*
Phone*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Is additional information about a change in your name, or your use of anassumed name or nickname, necessary to enable a check on your eligibility for membership?*
Please Explain:
Do you have a current valid NYS Driver's License?*
Please submit a picture of your current valid Driver's License:
Have you ever been convicted, or plead guilty to a felony, misdemeanor, insurance fraud, arson, or reduction of one of these offenses?*
Explain.
Do you agree to be tested for drugs or alcohol as part of your application for membership?*
OSHA regulations require that you pass a physical examination before becoming an interior firefighter. The Fire District’s designated physicians will provide you with a medical examination at NO COST to you. Will you be willing to undergo a medical examination?*

Employment Information
Are you Currently Employed?*
Company Name:
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
May the Eastport Fire Department contact your employer as a reference?
Contact Person
Contact Person Phone Number
Please enter a valid phone number.

Experience
Previous emergency service experience (include only fire, rescue or police and emergency medical service agencies). If applicable, attach copies of all fire, and rescue certifications held.
Service Experience
Attach Certifications

Cancelof
Have you ever been a member of the United States Armed Forces?
Date Started Service
Date Discharged From Service
Type of Discharge:
If Discharge was dishonorable, give complete details in space provided

Applicants Authorization for Release of Information
If order to confirm the information I have supplied on my application for membership with the Eastport Fire District. I authorize all licensing agencies, educational institutions, law enforcement agencies, present and former employers, and military services to disclose their relevant records about me to the Eastport Fire District whether the information be public, private or confidential in nature: and I release them from any liability and responsibility from doing so.

This authorization in original copy form shall be valid for this and any future information, reports or updates that may be requested. I understand that this form will accompany requests for official documents and confirmations of my credentials.
Date*

MonthDayYear
Date
Signature*

Clear

Privacy Notification
Section 94 of the Public Officers Law (personal Privacy Protection Law) requires that you be notified of the following facts when information which will be maintained in record systems is collected from you.

The authority to request and confirm personal information about you is found in Article 6 of the Executive Law.

The information obtained will:
- Be used to determine your qualifications for the position for which you are applying.
- Be released to the fire chief and your potential supervisors.
- Be maintained in your personal file (if you become a fire company member) or in our resume file for six months (if you are not a fire company member)
Failure to provide information or authorization will result in your application not being considered for membership.

The information will be maintained by the Secretary to the Fire District at Fire District offices.

Eastport Fire District

21 Union Avenue

PO Box 353

Eastport, New York 11941-0353

(631)325-0610

Fax: (631)325-8007
Date

MonthDayYear
Date
Signature*

Clear

Substance Abuse - Eastport Fire District
The Eastport Fire District recognizes drug and alcohol abuse as a modern-day problem affecting all professions. The Fire District also recognizes that many contributing factors cause certain individuals to use illegal drugs, abuse alcohol or abuse prescription drugs. Fire fighting and emergency medical service professions are not immune from these problems. Fire District employees and department members having such a problem are encouraged to seek diagnosis and follow through the treatment that may be prescribed by a qualified professional to address the problem as early as possible.

            The Eastport Fire District has the responsibility to provide the highest quality service to its taxpayers and the responsibility to ensure the safety of district employees and the general public it serves. Any impairment of an employee’s or members physical condition, because of substance abuse, may affect the district’s ability to meet these responsibilities.

            The following is the substance abuse policy of the Fire District covering all employees of the Eastport Fire District as well as members of the Eastport Fire Department.

            All employees and members are advised that violations of this substance abuse policy may result in disciplinary action that may include suspension, expulsion or termination from the Eastport Fire District or membership in the Eastport Fire Department.

            Copies of this policy shall be made available to all current Fire District employees and Fire Department members, and all employees and members shall sign acknowledgements that they have received the policy.

Substance Abuse Policy

             The use, sale, transfer, possession, distribution or manufacture of drugs or any controlled substances, drug paraphernalia, or any combination thereof, or the misuse of prescription medication, on any premises of the Eastport Fire District or work sites including, but not limited to, district owned vehicles and any private vehicles parked on district premises or work sites by employees of the Fire District or members of the Fire Department is strictly prohibited.

            Any member or employee who uses, sells, transfers, possesses, distributes or manufactures drugs or controlled substances on any premises or work sites of the district; or any employee or member found to be working with his/her ability impaired due to the use of alcohol, drugs, controlled substances, or misuse or prescription medications, will be subject to appropriate disciplinary action. Disciplinary action may include, but is not limited to, loss of wages, suspension with or without pay, suspension and/or expulsion from the department, and/or termination from employment of the district. The district may also pursue any and all additional legal remedies at its disposal.

Reasonable Suspicion Testing

             A employee of the Eastport Fire District and any member of the Eastport Fire Department shall submit to a drug screen test when at least two supervisors state they have reasonable suspicion to believe alcohol, drugs and/or controlled substances are affecting the employee’s or members behavior and/or performance. Should both supervisors have reasonable suspicion that an employee’s or member’s behavior and/or performance is affected by alcohol, drugs, or controlled substances, either supervisor shall order the employee or member to submit to a drug and/or alcohol test.

            Reasonable suspicion to believe the alcohol, drugs, or controlled substances are affecting the employee’s or member’s behavior and/or performance, shall be the only basis upon which testing may be initiated, and in all cases, justification of this reasonable suspicion shall be examined and approved by the Chief, or his designee or supervisor prior to requesting an alcohol or controlled substance test. The employee’s or member’s supervisor and another individual in the chain of command higher than the employee or member must personally observe abnormal behavior by the employee or member and/or an abnormality in the employee’s or member’s appearance, behavior, speech, or breath odor (among other things) before the employee or member is ordered to submit to a drug and/or alcohol test.

            When the Chief, or his designee or supervisor determines that reasonable suspicion exists, and this reasonable suspicion is collaborated by a second supervisor, the employee or member must submit to a drug and/or alcohol test. The employee must submit a sample at the required time and place, must cooperate with the collection of the sample, and must cooperate in the administration of the test and/or sign any document required for testing. Failure by the employee or member to cooperate in the administration of the testing shall be considered insubordination and may result in disciplinary action.

            An employee or member, during the period of testing or until the test results have been analyzed, and reviewed by the district, shall be transported to and from the collection site, and home, if required.

            In case of a positive test result, the employee or member may elect to have the same sample tested by the state-approved laboratory of his/her choice, at his/her expense within three (3) business days of notification of the initial positive test result.

I acknowledge receipt of and have read the Eastport Fire District “Substance Abuse Policy.” Dated, December 20th, 2010
Date*

MonthDayYear
Date
Signature*

Clear

Hepatitis B
I have been informed of the benefits of the Hepatitis B vaccine and…..*
Hepatitis B Vaccine Declination

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccination at this time.

I understand that by declining this vaccine (HBV), I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood and other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no expense to me.
Print Name*
Date*

MonthDayYear
Date
Signature*

Clear

Eastport Firefighters Benevolent Association

Membership Application
Personal Information from above.
Have you ever been a member of a Benevolent Association?
Name of Benevolent Association
Years of Membership
Beneficiary:
Name of Beneficiary*
Relationship*
Phone Number of Beneficiary*
Please enter a valid phone number.
A membership fee of five dollars and an application fee of ten dollars must be included with this application. Please make the fifteen dollar ($15) check out to the Eastport Firefighters Benevolent Association

Membership Form

Eastport Chemical Engine Company No. 1

21 Union Avenue, Eastport NY 11941

Instructions For Completing Application For Membership.

Personal Information

Employment Information

Experience

Applicants Authorization for Release of Information

Privacy Notification

Substance Abuse - Eastport Fire District

Hepatitis B

Eastport Firefighters Benevolent Association

Personal Information from above.

Beneficiary:

Suffolk County Volunteer Recruitment Program

Personal Information from above.