Applicant’s Full Name:
Last, First, Middle Initial
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Home Address:
Street Address, City, State, Zip Code
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| How long have you lived at this address?:
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| Home Phone #:
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| Cell Phone #:
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| Email Address:
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| Date of Birth:
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| Sex:
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Male
Female
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Please provide the last 5 digits of your social security number: :
This information is used to verify training certificates
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| Driver’s License #:
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| Driver's License Class :
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| Driver’s State Issued:
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| Height:
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| Weight:
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| Education and Employment |
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| Where are you currently employed::
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| Job Title:
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| Supervisor’s Name:
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| May we contact your supervisor?:
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Yes
No
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| Education Level:
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| Other Education:
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| Please list any other technical/professional degrees:
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| Previous Fire, Rescue, or EMS experience: |
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| Have you ever filed an application with the New Windsor Fire Department: : |
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Yes
No
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| If so, when? :
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| Have you ever been a member if any other fire or rescue department(s)?:: |
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Yes
No
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| If you have been a member of any other fire or rescue department please list department name(s) and date(s)::
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| Have you ever been denied membership to a fire and/or rescue department?:: |
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Yes
No
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| If so, please give details: :
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| Have you ever been discharged for misconduct or unsatisfactory service or asked to resign from a fire and/or rescue department?:: |
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Yes
No
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| If you have been discharged, please give details: :
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| List any firefighting and/or emergency medical certifications that are current. Please provide copies of the certifications: :
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Please provide copies of certifications::
Upload documents here: Acceptable formats include DOC, DOCX, PDF, XLS, XLSX, PPT, PPTX, TXT, JPEG, PNG
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| Please list any other professional or volunteer experience that you may have:
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| List any special training, skills or interests you may have:
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| Please list any medical restrictions that might/will affect your ability to fulfill the requirements for the classification of membership you have applied for:
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| Please list any restrictions that might/will affect your availability for volunteer work (work schedule, etc.):
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| Have you ever been convicted of a felony offense?:
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No
yes
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| If yes, please provide details :
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| Personal References |
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Reference #1:
Name, Address, Phone Number
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Reference #2:
Name, Address, Phone Number
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Reference #3:
Name, Address, Phone Number
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| Emergency Notification Information |
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Primary Emergency Contact #1:
Name, Relationship to You, Address, Phone Number, Additional Phone Number
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Emergency Contact #2:
Name, Relationship to You, Address, Phone Number, Additional Phone Number
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| ACKNOWLEDGEMENT |
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| Electronic Signature:
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| How did you hear about us? : |
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| Date Submitted:
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10/29/2024 2125 |
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
The facts set forth in my application for membership are true and correct. I understand that a false statement on this application may be considered cause for rejection of this application or termination of my membership. I hereby authorize the New Windsor Fire Department to conduct a work history, reference check, and/or police inquiries as it deems appropriate, and I further release the New Windsor Fire Department of any circumstances that may come out of any investigations. (Note: any information retrieved will be kept confidential and treated as personal). I understand that nothing contained in the membership application promises anything regarding membership, and I understand that no such promise is binding upon the New Windsor Fire Department unless made in writing.
If elected to the Department, I understand that I am a part of the New Windsor Fire Department, and therefore I can be requested to resign or be terminated or expelled from membership. Causes for termination or expulsion from membership may include, but are not limited to:
- Failure to comply with the bylaws of the Department
- Failure to comply with the policies and procedures of the Department
- Providing false or misleading information on this application
By my electronic signature above, I affirm that I have read and understood these statements and I further agree to the provisions contained herein.
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