ANGLETON VOLUNTEER FIRE DEPARTMENT APPLICATION FOR MEMBERSHIP

ANGLETON VOLUNTEER FIRE DEPARTMENT APPLICATION FOR MEMBERSHIP

Angleton Volunteer Fire Department, 221 North Chenango, Angleton, Texas 77515
PERSONAL
Last Name*
First Name*
Middle Name*
Street Address*
City/Town*
State*
Zip*
Previous Address (if less than 3 years at current address)
Telephone Number*
Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Age*
Sex*
U.S. Citizen*
Place of Birth*
Marital Status*
Email Address*
Email Address
Social Media Accounts (Facebook, Instagram, etc...If none, enter N/A.)*
How did you hear about us?*
The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex, national origin or disability, (As does the Americans with Disabilities Act). Federal Law also prohibits discrimination on the basis of age with respect to certain individuals.
Occupation*
Name and Address of Current Employer*
Valid Driver's License?*
State*
Restrictions*
MEDICAL
Height*
Weight*
Blood Type (If unsure, please enter N/A)*
Have you had or do you have any impairments of sight, hearing, speech and/or any mental or physical disabilities? If so, please describe.*
Do you have any known allergic reactions to smoke, poison ivy/oak, insect stings, etc? If so, please describe.*
Have you had any serious illnesses or injuries in the last five years? If so, please describe and give any work limitations.*
Have you ever received compensation for injuries or on current worker's compensation? If yes, describe fully.*
EMERGENCY CONTACT
Name*
Relationship*
Telephone Number*
Format: (000) 000-0000.
FIRE SERVICE

(you may include volunteer positions)
Have you ever been a member of the Angleton Fire Department?*

YesNo
If yes, dates of service.
Are you presently a member of a fire department?*

YesNo
Name, phone number, and address of department.

Do you hold any of the following certifications? If yes, give date first certified, level of certification and date(s) of expiration. If no, please enter N/A in the first cell.*

Rows	Date of first certification	Level of certification	Expiration date
CPR
Medical (ex. First Aid, EMT, etc.)
Firefighter I or II
Technical Rescuer
NFPA 1403
Other(s) please specify

Have you served on any other fire/EMS agency? If so which department(s), date(s) of service, and reason for leaving.*
Have you had any specialized training, skills, experience or qualifications that you feel might be of benefit to the Angleton Fire Department? If yes, describe. This includes any applicable certifications.*
MILITARY SERVICE
Have you ever served in the Armed Forces of the United States or the National Guard?*

NoYes
If yes, what was your highest rank? If inapplicable, please enter N/A.
Branch (If inapplicable, please enter N/A.)*
Dates of Service [From - To] (If inapplicable, please enter N/A.)*
Type of Discharge (If inapplicable, please enter N/A.)*
Date of Discharge (If inapplicable, please enter N/A.)*
Service Job Description (If inapplicable, please enter N/A.)*

References*

Rows	Name	Address	Telephone
Ref. 1
Ref. 2
Ref. 3

For your references, please do NOT list family members. Preferred references are previous managers/bosses, co-workers, etc.
EDUCATION

If inapplicable, please enter N/A in the first cell.

Rows	Name and Address	Graduated (Yes / No)	Number of Years Attended	Degree	Major
High School
College
Graduate
Business / Trade
Other: (Equivalency, etc.)

High School Diploma

Please upload your high school diploma.
Cancelof
CRIMINAL RECORD
Have you ever been convicted of a crime?*

YesNo
If yes, please describe. If no, please enter N/A.*
Have you ever been charged with traffic violations?*

YesNo
If yes, please describe. If no, please enter N/A.*
Applicants shall submit a Type 3 Driver's Record from the Texas Department of Public Safety along with their completed application at their expense.
NOTICE TO APPLICANT
The completion of this application does not indicate that there are vacant positions with the Angleton Fire Department and in no way obligates this department nor the City of Angleton.

I hereby authorize Angleton Fire Department to conduct a personal background investigation including school(s) attended, former and present employers, residences, named references, criminal and motor vehicle check in connection with my application for membership.

I understand that I am financially responsible for obtaining and submitting the Type 3 Driver's Record from the Texas Department of Public Safety along with my application for membership.

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 previous notice. I understand that I do not have a contract of employment and no one is authorized to make such promise. I also understand this agency is a volunteer agency and if I am accepted into membership that I will not receive any compensation.
Signature of Applicant*
Date*

MonthDayYear

DPS Computerized Criminal History (CCH) Verification

(AGENCY COPY)
I, APPLICANT or EMPLOYEE NAME* , acknowledge that a Computerized Criminal History (CCH) check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on name and DOB identifiers I supply. (This is not a consent form.) Authority for this agency to access an individual's criminal history data may be found in Texas Government Code 411; Subchapter F.

Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, therefore the organization conducting the criminal history check is not allowed to discuss with me any criminal history record information obtained using this method. The agency may request that I have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search. Once this process is completed the information on my fingerprint criminal history record may be discussed with me.

In order to complete the process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to the fingerprinting services company.
(This copy must remain on file by your agency. Required for future DPS Audits)
Signature of Applicant*
Date*

MonthDayYear
Agency Name
Agency Representative Name
Signature of Agency Representative
Date

MonthDayYear
Please: Check and Initial Applicable Space

For internal use. Applicant to leave blank.
CCH Report Printed:

YesNo
Initial:
Purpose of CCH:
EmployeeVolunteer/Contractor
Initial:
Date Printed

MonthDayYear
Initial:
Destroyed Date:

MonthDayYear
Initial:
Retain in your files
Should be Empty:

ANGLETON VOLUNTEER FIRE DEPARTMENT APPLICATION FOR MEMBERSHIP

PERSONAL

MEDICAL

EMERGENCY CONTACT

FIRE SERVICE

MILITARY SERVICE

EDUCATION

CRIMINAL RECORD

NOTICE TO APPLICANT

DPS Computerized Criminal History (CCH) Verification