|
| Personal Information |
|
| Last Name:
|
 |
|
| First Name:
|
|
|
| Middle Name:
|
|
|
| Current Address:
|
|
|
| City:
|
|
|
| State:
|
|
|
| Zip Code:
|
|
|
| Home Phone:
|
|
|
| Work Phone:
|
|
|
| Cell Phone:
|
|
|
| Social Security Number:
|
|
|
| Email Address:
|
|
|
| Do you have a valid Drivers License?:
|
|
|
| State of Issue:
|
|
|
| License Number:
|
|
|
| Expiration Date:
|
|
|
| License Class:
|
|
|
| CDL:
|
|
Yes
No
|
| Total Current Points:
|
|
|
| Have your driving privileges ever been suspended or revoked? :
|
|
|
| If yes, Why?:
|
|
|
| Are you a U.S. CItizen?:
|
|
|
| If not, place of origin?:
|
|
|
|
| Emergency Contact Information |
|
| In Case of Emergency Contact:
|
|
|
| Emergency Contact Address:
|
|
|
| Emergency Contact City:
|
|
|
| Emergency Contact State:
|
|
|
| Emergency Contact Phone #:
|
|
|
| Emergency Contact Relationship:
|
|
|
|
| Military / Employment Experience |
|
| Have you ever served in the armed forces?:
|
|
|
| Branch:
|
|
|
| Type of discharge:
|
|
|
| Military Start Date:
|
|
|
| Military End Date:
|
|
|
| Current Occupation:
|
|
|
| Employer's Name:
|
|
|
| Employer's Address:
|
|
|
| Employee's Supervisor:
|
|
|
| Employee's Supervisor Phone #:
|
|
|
| May we contact this person?:
|
|
|
| Start Date:
|
|
|
| End Date:
|
|
|
|
| Criminal Information |
|
| Other than minor traffic offenses, have you ever been convicted of a criminal act, or have any criminal charges pending?:
|
|
|
| If yes, Please explain:
|
|
|
|
| Education Experience |
|
| Related training you bring to the company (ex. CPR):
|
|
|
| List any other organizations you belong to:
|
|
|
|
| References |
|
| Provide three (3) references, not related to you. Please provide a name, address and phone number for all three:
|
|
|
| Please provide the names of any fire company personnel you are acquainted with (if any):
|
|
|
| Are you a member of any other Fire, EMS, or Rescue organization?:
|
|
|
| Fire / Rescue / EMS Type:
|
|
|
| Why are you leaving?:
|
|
|
| Have you ever been rejected from this or any other Fire, EMS, or Rescue organization?:
|
|
|
| If yes, explain:
|
|
|
|
| Current Fire / EMS Certifications (If Any) |
|
| CPR Expiration Date:
|
|
|
| EMS Certification Level:
|
|
|
| Enter EMS Certification ID #:
|
|
|
| EMS Certification Expiration Date:
|
|
|
Fire / Rescue Training:
Enter all current Fire / Rescue Certifications
|
|
|
NIMS ICS 100:
Date Obtained
|
|
|
NIMS ICS 200:
Date Obtained
|
|
|
NIMS ICS 300:
Date Obtained
|
|
|
NIMS ICS 400:
Date Obtained
|
|
|
NIMS ICS 700:
Date Obtained
|
|
|
NIMS ICS 800:
Date Obtained
|
|
|
|
| General Information
(* Optional)
NOTE: you must be 15 years and 11 months or older to apply. You must be 16 on the night the company
votes on your application. |
|
| Date of Birth:
|
|
|
| Why do you want to be a member of the Hampstead Fire Engine & Hose Company #1?:
|
|
|
All members are expected to actively support company fund raising, training, and community service functions and attend company meetings. Please indicate your areas of special interest::
Select all that apply
|
|
|
|
| NOTE:
NO APPLICATION WILL BE ACCEPTED WITHOUT THE FIRST YEARS DUES PAID IN FULL! |
|
| In order to be considered for membership you must submit a recent photo with your completed application.:
|
|
|
|
| I certify that all statements are true. I understand that any false statements made will be grounds for rejection or dismissal. I agree to abide by the By-Laws and rules of the Hampstead Volunteer Fire Engine & Hose Company #1 |
|
|
| By typing my name I am certifying that all the information is honest and correct. |
|
| Signature of Applicant:
|
|
|
| Signature of Parent or Guardian (If applicant is under 18):
|
|
|
| Date of submission:
|
|
05/24/2025 2127 |
|
| Upon submission of this application you will be directed to our PayPal page so you may pay the $5.00 application fee. |
|
May 31, 2025
