Rockville Volunteer Fire Department Membership Application

Rockville Volunteer Fire Department Membership Application

Apply to become a member of the Rockville Volunteer Fire Department. Please complete the information below. All fields can be edited until the form is submitted.
Applicants must be at least 16 years old at the time of this application.
Category of Membership Applying For
PERSONAL INFORMATION
Full Name

First NameMiddle NameLast Name
Email Address (for RVFD communications)
example@example.com
Confirm Email Address
example@example.com
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Birth Date

MonthDayYear
Date
Age
List each city and state in which you have resided within the past 10 years
Briefly state why you want to join the Rockville Volunteer Fire Department
Residency
Do you presently live more than 25 miles from Rockville, MD? Although not automatically disqualified from membership, applicants who will not be living within 25 miles of Rockville, Maryland should give careful and objective consideration to whether they will be able to meet RVFD's weekly standby shift and training requirements
Is there a reasonable possibility that within the next three years you will relocate more than 25 miles from Rockville?
Are you planning to move to within 25 miles of the Rockville, MD area?
Planned Relocation Date (if applicable)

MonthDayYear
Date
Are you presently a student at an academic institution located more than 25 miles from Rockville, Maryland?
Is there a reasonable possibility that within the next three years you will enroll in an academic institution located more than 25 miles from Rockville, Maryland?
If you will not be living within 25 miles of Rockville, please explain how you plan to meet standby and training requirements or administrative duties (if applicable)
Language Proficiency

If a member does not understand and speak English proficiently, it is likely that he/she will not be able to comprehend and respond to the type of rapid sequences of verbal commands common at emergency scenes. The inability to quickly comprehend and respond to instructions on emergency scenes can be dangerous to the emergency responders and to the public served by the Department. Accordingly, although RVFD welcomes diversity and encourages persons of all nationalities to apply, it is essential that every RVFD operational member understand and speak English with proficiency. Accordingly, although RVFD welcomes diversity and encourages persons of all nationalities to apply, it is essential that every RVFD operational member understand and speak English with proficiency.
Do you understand and speak English proficiently?
Eligibility to Work

If you are offered the opportunity to stand for membership, you will be required to produce identification and a Social Security card. If you do not have a Social Security card, you will be required to produce other satisfactory evidence of your right to work in the United States (e.g., a valid visa).
Are you legally eligible to work in the United States?
Administrative Qualifications (select all that apply)

Other
Provide details for any administrative qualifications selected above
LEGAL BACKGROUND

The fact that an applicant has a criminal conviction or has been the subject of a restraining order will not automatically result in disqualification. RVFD will consider the totality of circumstances when evaluating whether an applicant is qualified to become a member including, but not limited to: (a) the seriousness of the offense; (b) the relationship of the offense to the public trust; (c) whether the offense was a crime of moral turpitude; (d) the recency of the conviction or order; (e) the applicant's age at the time of the underlying incident; (f) the amount of time that has elapsed since the date of conviction or order; (g) whether the underlying conduct was isolated or part of a pattern of behavior which suggest the exercise of poor judgment; and (h) the extent of the applicant's rehabilitation since the conviction or date of order.
FAILURE TO DISCLOSE A CONVICTION MAY RESULT IN DISQUALIFICATION. ALL APPLICANTS ARE FINGERPRINTED AND SUBJECTED TO BACKGROUND REVIEWS.

Applicants are not required to disclose juvenile court proceedings
Have you ever been convicted of a crime or given probation before judgment for any offense other than minor traffic violation?
If yes, for each offense state: (a) date and place of disposition; (b) offense; (c) sentence imposed. If not applicable, type NA.
Have you ever been convicted or received probation before judgement for a driving offence, other than for a minor traffic violation?
Driving Offences (check all that apply)

Other
For each class of conviction checked above, provide: (a) offense; (b) date and place of conviction; (c) sentence/fine imposed.
Has your driver's license ever been suspended or revoked?
If yes, state when, where and why your license was suspended or revoked. If not applicable, type NA.
Have you ever been the subject of a peace order, restraining order, or other order barring you from having contact with another person?
If yes, provide an explanation.
Are you presently charged with or under indictment for a crime (including any serious traffic offense for which you must appear in court)?
To your knowledge, are you presently the subject or target of a criminal investigation?
FIRE/EMS BACKGROUND/QUALIFICATIONS/HISTORY

Previous fire/EMS experience is NOT required to become a member
Have you ever been a member of the Rockville Volunteer Fire Department?
If yes, when did you leave and why?
Previous Fire/Rescue Departments

Either in Montgomery County or elsewhere in Maryland or out-of-state.
Are you currently a member of another fire/rescue or EMS department in Montgomery County?
Do you possess a MCFRS/FROMS 'Fit For Duty' letter issued within the last year?
Department Name (if currently a member elsewhere)
Are you currently on the Montgomery County IECS list?
Do you intend to resign or remain at that department?
Were you previously a member of any other fire/rescue or EMS department?
Location
Department Name
Years of Service
Final Rank Held
Reason for Leaving (If remaining a member, enter N/A)
Name of Authorized Point of Contact for a Reference

First NameLast Name
Contact's Title/Rank
Contact's Email Address
example@example.com
I would like to add information for a second prior department
Location
Department Name
Years of Service
Final Rank Held
Reason for Leaving (If remaining a member, enter N/A)
Name of Authorized Point of Contact for a Reference

First NameLast Name
Contact's Title/Rank
Contact's Email Address
example@example.com
RVFD verifies fire/rescue/EMS background

An affirmative answer to any of the following questions will not automatically disqualify you from consideration for RVFD membership, but a false answer may result in rejection of your application or termination of membership.
Check each of the following which are TRUE (regarding volunteer department service history)
Fire and/or EMS certifications and licenses (check all that apply)

Other
Have you ever held an EMT or Paramedic license that has been revoked or suspended?
If yes, provide a complete explanation
Describe any other qualifications or experiences that are not directly fire/rescue related that may be beneficial in the fire/EMS service
EDUCATIONAL BACKGROUND

NOTE: Members under eighteen years of age must either:be enrolled in an academic institution and earning satisfactory grades; or possess a high school diploma or GED.Adults without a high school diploma or GED, and who are not actively enrolled in an academic program are generally not recommended for membership.
Have you been awarded a high school diploma or GED?
Last High School Attended (name, city, state, years of attendance)
Are you currently attending a college or university or completed undergraduate education?
Identify each institution attended, dates attended, and any degrees awarded.
Currently attending or completed any graduate/post-graduate or professional education?
List each institution, dates attended and degrees awarded (graduate/professional)
Any other educational programs such as tech college, trade school, certificate programs, etc.?
Do you speak any language other than English?
List languages spoken.
Do you have an employment history?
Current or Most Recent Employer
Position/Job Title (Current or Most Recent)
Start Date (Current or Most Recent Employer)

MonthDayYear
Date
Current Employer Point of Contact Name

First NameLast Name
Contact's Email Address (Current Employer)
example@example.com
Contact's Phone (Current Employer)
Please enter a valid phone number.Format: (000) 000-0000.
Do you have an employer prior to your current employer?
1st Most Recent Employer
Position/Job Title (1st Most Recent)
Start Date (1st Most Recent Employer)

MonthDayYear
Date
End Date (1st Most Recent Employer)

MonthDayYear
Date
1st Most Recent Employer Contact Name

First NameLast Name
Contact's Email (1st Most Recent Employer)
example@example.com
Contact's Phone (1st Most Recent Employer)
Please enter a valid phone number.Format: (000) 000-0000.
Reason for leaving your 1st most recent job
Do you have an employer prior to the 1st most recent employment (2nd most recent)?
2nd Most Recent Employer
Position/Job Title (2nd Most Recent)
Start Date (2nd Most Recent Employer)

MonthDayYear
Date
End Date (2nd Most Recent Employer)

MonthDayYear
Date
2nd Most Recent Employer Contact Name

First NameLast Name
Contact's Email (2nd Most Recent Employer)
example@example.com
Contact's Phone (2nd Most Recent Employer)
Please enter a valid phone number.Format: (000) 000-0000.
Reason for leaving your 2nd most recent job
Personal References

READ THIS BEFORE LISTING REFERENCES. Applicant must provide all requested information (including current email addresses) for three personal references. It is the Applicant's responsibility to notify each reference that an RVFD representative will be contacting him/her by email. List Only references that you have known for three years. Do NOT list immediate family or household members as references. Only ONE reference from the following categories will be accepted: extended family, teacher, coach, professor, instructor. WE CHECK REFERENCES. PLEASE ASK YOUR REFERENCE TO RESPOND PROMPTLY.
1st Reference Name

First NameLast Name
1st Reference Email
example@example.com
1st Reference Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
1st Reference Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1st Reference Relationship

Other
2nd Reference Name

First NameLast Name
2nd Reference Email
example@example.com
2nd Reference Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
2nd Reference Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
2nd Reference Relationship
3rd Reference Name

First NameLast Name
3rd Reference Email
example@example.com
3rd Reference Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
3rd Reference Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
3rd Reference Relationship
Additional Information Relevant to Your Application
UNDERSTANDING SHIFT AND TRAINING COMMITMENTS

Each new member (other than auxiliary or administrative) is appointed to a standby shift and must be present for that shift each week unless on scheduled leave or otherwise excused. There are six overnight standby shifts (5:00 PM - 7:00 AM). Additionally, each shift rotates to a Saturday night every six weeks. Applicants with conflicting employment or educational commitments may arrive for an overnight standby shift as late as 7:00 PM. High school students are excused at 11:00 PM on nights preceding school days. There are two weekend day standby shifts (7:00 AM to 5:00 PM).Members are granted a fixed number of "vacation/leave days" per year and may also be excused by their shift officers due to illness, family emergencies, etc. Training commitments are in addition to standby shift requirements. During the first year of membership, members taking EMT and fire courses are frequently in class at the academy two evenings per week. Some courses also have classes scheduled on weekends.
CERTIFICATION

I hereby certify that the statements contained herein are true and correct to the best of my knowledge. I understand that, should an investigation disclose material misrepresentation, omissions, or falsification, my application will be rejected, or, if I am a member, my membership and all rights and privileges thereof may be immediately terminated. My electronic initials on this application indicates that I have read the description for the volunteer positions available to me and I understand that the position of a firefighter or emergency medical services provider is physically challenging and that my membership is dependent on my successful completion of a physical examination and a favorable background investigation. I further understand that this application form is not a guarantee of membership, nor an offer of membership.The RVFD Membership Recruitment & Retention Committee will conduct Station Tours / Information Sessions for new applicants during the application process. All applicants must attend one of the station tours/information sessions. The purpose is to assure that all applicants fully understand the responsibilities of RVFD membership. The applicant will not be considered for membership until he/she has attended one of these station tours/information sessions.I also understand that an incomplete, inaccurate, or illegible application may be returned or withdrawn; that the General Membership has sole authority to act upon my “Application for Membership;” that the decision of the General Membership is final and not appealable; and that I may not reapply for one year following a denial of membership. I have read the statements above and, by entering my initials in the box below and/or signing the application, I agree to these provisions.The Rockville Volunteer Fire Department, Inc. is an Equal Opportunity Employer. It values diversity in the workplace. Women and men of all ages are encouraged to apply without regard to cultural and ethnic backgrounds, religious belief, political affiliation, national origin, or sexual orientation.
By signing, you certify that all information provided is accurate and you understand the requirements of becoming a volunteer firefighter or EMS provider.
Applicants under the age of 18: Name of parent or guardian approving application

First NameLast Name
Approving Parent's or Guardian's Email
example@example.com
Approving Parent's or Guardian's Phone
Please enter a valid phone number.Format: (000) 000-0000.
By signing my name in this box, I am the parent or guardian approving this application
Should be Empty:

Rockville Volunteer Fire Department Membership Application

Applicants must be at least 16 years old at the time of this application.

PERSONAL INFORMATION

Residency

Language Proficiency

Eligibility to Work

LEGAL BACKGROUND

FAILURE TO DISCLOSE A CONVICTION MAY RESULT IN DISQUALIFICATION. ALL APPLICANTS ARE FINGERPRINTED AND SUBJECTED TO BACKGROUND REVIEWS.

FIRE/EMS BACKGROUND/QUALIFICATIONS/HISTORY

Previous Fire/Rescue Departments

RVFD verifies fire/rescue/EMS background

EDUCATIONAL BACKGROUND

Personal References

UNDERSTANDING SHIFT AND TRAINING COMMITMENTS

CERTIFICATION