WILTON FIRE DISTRICT/WILTON FIRE DEPARTMENT270 BALLARD ROAD, WILTON, NEW YORKAPPLICATION FOR NEW MEMBERSHIP
APPLICANT INFORMATION
Name:
First Name
Last Name
Date of birth:
-
Month
-
Day
Year
Date
Home Phone:
Cell Phone:
Current address:
Address Details
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long at current address?
Email:
example@example.com
Education:
Is additional information about a change in your name or your use of an assumed name or nickname necessary to enable a check on your eligibility for membership? (please check one) If yes, explain:
Yes
No
Have you ever been convicted or pled guilty to a felony, misdemeanor, insurance fraud, arson, or a reduction of one of these offences? If "Yes" provide a brief description. Please note, an Arson/Sex/Criminal Offense Records Check will be performed by the Fire District.
Yes
No
Have you ever been a member of this company or any other Emergency Services organization? (Fire, Rescue, EMS or Police) (use space on last page of application marked "Additional Information" if needed).
Yes
No
Agency:
Address:
Phone:
Contact:
Yrs. Experience
Positions Held:
MILITARY SERVICE
Have you ever been a member of the United States Armed Forces? If yes please include branch and dates of service;
Yes
No
If yes please include branch and dates of service:
If the answer is "Yes" did you receive an honorable discharge?
Yes
No
(Dishonorable discharge is not an absolute bar to membership. This and other factors will affect a final membership decision. If the above answer is "No", please provide a brief description of the circumstances.
AVAILABILITY
Please indicate your availability to participate in normally required fire department activities (meetings, drills, and emergency calls). Please check the appropriate time periods:
Weekends:
Days
Evenings
Nights
Weekdays:
Days
Evenings
Nights
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WILTON FIRE DISTRICT/WILTON FIRE DEPARTMENT270 BALLARD ROAD, WILTON, NEW YORKAPPLICATION FOR NEW MEMBERSHIP
MEDICAL SCREENING
OSHA regulations require that you pass a physical examination before becoming an active member of the fire department. All Wilton firefighters are required to have a medical examination. This is provided free of charge by the Fire District medical provider. Will you be willing to undergo a medical examination?
Will you be willing to undergo a medical examination?
Yes
No
BACKGROUND CHECK
Wilton Fire District uses ClearChecks to perform background checks for potential members. You will be receiving an email from ClearChecks. The email will provide you with disclosures, consents, and a form to fill out. The background check is a requirement for membership and should be completed in a timely manner.
Do you consent to a background check from Wilton Fire District?
Yes
No
EMPLOYMENT
Are you currently employed?
Yes
No
If "Yes" may we contact your employer as a reference?
Yes
No
Employer:
Address:
Phone:
EMERGENCY CONTACT
Name:
Address:
Phone:
PLEASE LIST THREE PERSONAL REFERENCES, OTHER THAN MEMBERS OF THIS ORGANIZATION or FAMILY MEMBERS, WHO HAVE KNOWN YOU FOR AT LEAST THREE YEARS.
Name:
Address:
Phone:
Name:
Address:
Phone:
Name:
Address:
Phone:
Please list any acquaintances that are members of the Wilton Fire Company:
It is my desire to become an Active Member of the Wilton Volunteer Fire Company, Inc. I shall abide by the Constitution and By-Laws governing said Company. To the best of my knowledge, I do not have any mental or physical condition that will restrict the full performance of my duties in the fire company. Exceptions to the above are as follows:
WITH IN THE FREEDOM OF INFORMATION LAW, ALL INFORMATION CONTAINED OR OBTAINED HEREIN WILL REMAIN CONFIDENTIAL AND WILL BE USED ONLY FOR INTERNAL MEMBERSHIP PROCESSING.
IN WITNESS WHEREOF, this application has been subscribed this
Day of , 20
By the undersigned applicant who affirms that the statements made herein are true under the penalties of perjury. Entering false data can be cause for removal.
Signature of applicant:
Date:
-
Month
-
Day
Year
Date
Witnessed by:
Date:
-
Month
-
Day
Year
Date
To be completed for persons under 18 years of age:
I give my consent for
to file an application to become a member of the Wilton Volunteer Fire Company,, Inc.
Parent/Legal Guardian:
Date:
-
Month
-
Day
Year
Date
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WILTON FIRE DISTRICT/WILTON FIRE DEPARTMENT
270 BALLARD ROAD, WILTON, NEW YORK
APPLICATION FOR NEW MEMBERSHIP
CHIEF
I, Fire Chief of the Wilton Fire District, after having interviewed, and having received his/her word of honor to uphold our Constitution and By-Laws and to uphold the position of Firefighter, by remaining in good standing with the Chief's requirements, I hereby recommend that the above mentioned individual be accepted by the fire company and by the Board of Fire Commissioners.
Fire Chief:
Date:
-
Month
-
Day
Year
Date
MEMBERSHIP
Recommended:
Yes
No
Status Recommended:
Fire District Resident:
Yes
No
Station Assigned:
1
2
Membership Committee Signatures:
As President of the Wilton Volunteer Fire Company, Inc., I hereby recommend this applicant to the Board of Fire Commissioners for consideration for membership. Driver's License copy, LENS approval form, Interview form, Reference Check Information, drug/alcohol test consent agreement and Arson/Sex Offense check form are attached.
Approved by the Company on:
President:
BOARD OF FIRE COMMISSIONERS
We the undersigned Commissioners, approve the applicant to membership as stated above.
Approval by the Board:
Medical Report Received:
Badge Number Assigned:
ADDITIONAL INFORMATION
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Revision 2024
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