WVFD New Member Application

Town of Wethersfield Wethersfield Volunteer Fire Department

Membership Application

Name*

First NameLast Name

MI

Date of Birth*

Date

Address*

License Number*

Email*

example@example.com

Home Phone

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

Cell Carrier*

Are you a Veteran of the U.S Military?*

YesNo

If yes, What branch?

If yes, What Rank?

Current Occupation*

Duties*

Present Employer*

Length of Service*

Employer Address*

Office Phone

Please enter a valid phone number.

Work Schedule

DaysNights

Hours

Rotating Shift

YesNo

EMPLOYMENT HISTORY-LIST PAST EMPLOYERS IF YOU HAVE BEEN AT CURRENT EMPLOYMENT FOR LESS THAN 5 YEARS

Past Employer

Position

Service Dates

Past Employer

Position

Service Dates

Past Employer

Position

Service Dates

EDUCATION HISTORY - -COPIES OF DIPLOMAS OR CERTIFICATES MUST BE PRESENTED UPON REQUEST

Name and Location of High School Attended

Did You Graduate?

YesNo

Date Graduated

Date

If not, Have you passed a GED Test?

YesNo

Where

Date Received

Date

List Any Colleges, Business Schools, Or Fire Service Training Attended

	Name of School	Location	Course/Major	Dates Attended	Degree/Certificate
1
2
3
4

Do you have any previous Fire Service experience?*

YesNo

If Yes, Department Type.

VolunteerCareerCombination

If yes name of the department

City/Town/State

Highest Rank Held

Length of Service

Fire Training/ Certifications Obtained.

Give the name of one (or more) members of the Department to whom you are personally known:

Give the names of two people, not Department members and not related to you, who know you through school, business or personal association:

Name*

Address*

Phone*

Name*

Address*

Phone*

Have you ever been convicted of a felony or misdemeanor other than a minor traffic violation?*

YesNo

A conviction does not automatically mean that you cannot be taken as a member. The type of Conviction and how long ago it happened is important. Give us all the facts:

The completion of this application does not indicate that there are vacant positions in the Wethersfield Volunteer Fire Department and in no way obligates the Town of Wethersfield. I understand that if I am offered membership in the Wethersfield Volunteer Fire Department of the Town of Wethersfield, such membership is contingent upon my supplying the proper identification and authorization documents required under the Immigration Control and Reform Act of 1986. I hereby authorize the Wethersfield Volunteer Fire Department to conduct a personal background investigation including school attended, former and present employers, residences, named references, criminal and motor vehicle record check in connection with my application for mem- bership. I further understand that misrepresentation or omission of facts called for in the application process is cause for Lack of Acceptance or dismissal. Further, I understand/agree that membership is for no definite period and may be terminated at any time without any previous notice. I understand that I do not have a contract of employment and no one is authorized to make any such promise. Membership is contingent upon applicant passing a job-related physical examination and a drug test.

Signature of Applicant*

Date Signed

Date

DEPARTMENT/COMPANY ACCEPTANCE OF APPLICANT

The undersigned office has confirmed that the applicant meets the Wethersfield Volunteer Fire Department requirements for mem- bership. The applicant is at least 18 years of age and has completed the minimum educational requirements.

Chief of the Department

Notice To Applicant