Citizen’s Hose Co. of Jersey Shore
Membership Application
Specify Type of Application:
(check all that apply)
________ -Firefighter
______-Paid EMT
________-Rescue Technician ______-Paid Paramedic
________-E.M.S. (Volunteer)
________-Cadet (under 18yrs old)
________-Fire Police
________-Driver (engineer)
________-Fire Prevention
________-Fundraising
Personal Data:
Name (First,Middle,Last)___________________________________________________
Address_________________________________________________________________
City, State, Zip___________________________________________________________
Phone (Home)_____________________ Phone (Work)__________________________
Date of Birth________/___________/____________ Driver’s License #_____________
Marital Status____________________________________________________________
Social Security # __________-____-_________
E-Mail address__________________________
If under age 18, Parents Name(s)_____________________________________________
Education:
(Circle the Highest Grade Completed) 7 8 9 10 11 12 13 14 15 16 17+
Name & Address of Your High School________________________________________
Date Graduated:________________________
Name & Address of Technical School or College________________________________
Date Graduated:________________________
Employment:
Employer Name__________________________________________________________
Address_________________________________________________________________
Supervisor’s Name___________________________ Phone Number_(___)____-_______
Date Started_________/________/________ Date Ended_______/_______/_____
Reason For Leaving_______________________________________________________
Employer Name__________________________________________________________
Address_________________________________________________________________
Supervisor’s Name___________________________ Phone Number_(___)____-_______
Date Started_________/________/________ Date Ended_______/_______/_____
Reason For Leaving_______________________________________________________
Training And Experience:
Have you been or are you currently a member of a Fire Dept., Rescue Squad, Ambulance Service or other similar organization(s)?_______________________________________
If Yes, Name and Address of Organization_____________________________________
_______________________________________________________________________
Dates of Service__________________________________________________________
Positions Held____________________________________________________________
Chief’s Name and Phone #__________________________________________________
Please List all Fire, Rescue & Haz-Mat Training: (Please photocopy and attach copies)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
EMT or Paramedic Certification #____________________ Exp. Date___/_____/____
_____ AHA Basic Cardiac Life Support Exp. Date___/_____/____
_____ AHA Advanced Cardiac Life Support Exp. Date___/_____/____
Investigative Information:
May the Citizen’s Hose Company of Jersey Shore contact your present or previous employers or other organizations listed to ask questions concerning your character or abilities? ___________
If no, please explain_______________________________________________________
_______________________________________________________________________
Have you ever been dismissed from any position?__________
If yes, please explain_______________________________________________________
________________________________________________________________________
Have you ever been forced to resign any position?__________
If yes, please explain_______________________________________________________
________________________________________________________________________
Have you ever been arrested, summoned into court as a defendant or indicted, convicted, fined, imprisoned, or placed on probation, or has any case been filed against you?______
If yes, please explain_______________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Authorization For Release of Information
To whom it may concern:
I hereby authorize any investigator or duly accredited representative of the Citizen’s Hose Company bearing this release or a copy thereof: within one year of it’s date to obtain any information from schools, residential management agents, employers, criminal justice agencies, or individuals relating to my activities. This information may include, but is not limited to, academic, residential, work attendance, personal history, disciplinary, driving, arrest, and conviction records.
I hereby release any individual including record custodians, from any and all liability for damages of whatever kind or nature may at any time result to me on account of compliance, or any attempts to comply, with this authorization. Should there be any question as to the validity of this request, you may contact me as indicated below.
Signature (Full Name)______________________________________________________
Full Name (Please Print)____________________________________________________
Other Names Used________________________________________________________
Parent or Guardian (If Required)_____________________________________________
Date______________/____________/____________
Current Address ______________________________________________________
______________________________________________________
______________________________________________________
Telephone Number ( )______-_________
Intent of Form
Information from this form will be furnished to individuals to obtain information regarding your activities in connection with an investigation to determine your fitness for membership to the Citizen’s Hose Company of Jersey Shore and it’s divisions Jersey Shore Area EMS and Citizen’s Hose Company Fire and Rescue Division.
References:
(List three people who are not related to you by blood or marriage who are familiar with your education and work experience.)
Name___________________________________________________________________
Address_________________________________________________________________
City, State, Zip___________________________________________________________
Phone___________________________________________________________________
Name___________________________________________________________________
Address_________________________________________________________________
City, State, Zip___________________________________________________________
Phone___________________________________________________________________
Name___________________________________________________________________
Address_________________________________________________________________
City, State, Zip___________________________________________________________
Phone___________________________________________________________________
I authorize investigation of all statements in this application. I understand that misrepresentation or omission of facts asked for is cause for dismissal.
Signature___________________________ Date__________________________
If the applicant is less than the age of 18 then a parent
must sign below.
I am aware of my child’s decision to join the Citizen’s Hose Company of Jersey Shore. I give my permission to him/her to join. I have read the completed application and agree to it’s content being truthful and concur with statements allowing Citizen’s Hose Company of Jersey Shore to perform an investigative background check concerning my child’s character and work habits.
Signature__________________________ Date__________________________
“The following
information is requested by the Federal Government in order to monitor
compliance with Federal laws prohibiting discrimination against applicants
seeking to participate in the program.
You are not required to furnish this information, but are encouraged to
do so. This information will not be
used in evaluating your application or to discriminate against you in any
way. However, if you choose not to
furnish it, we are required to note the race national origin of individual
applicants on the basis of visual observation or surname.”
Statistical Information:
Race Category: Ethnic origin category:
___American Indian or Alaska Native ___Hispanic or Latino
___Asian ___Not Hispanic or Latino
___Black or African American
___Native Hawaiian or Other Pacific Islander Sex: ___Male
___White ___Female
“This is an Equal Opportunity Program. Discrimination is prohibited by Federal Law. Complaints of discrimination may be filed with the Secretary of Agriculture, Washington D.C. 20250”
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _
(Please do not write below this line)
Date application received & entered in log______________________
Interview Date____________________________________________
Membership approval______________________________________
Entered company database__________________________________
Comments_______________________________________________________________________________________________________________________________________________________________________________________________________________