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| Personal Information |
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| Last Name:
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| First Name:
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| Middle Name:
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| Current Address:
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| City:
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| State:
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| Zip Code:
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| Home Phone:
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| Work Phone:
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| Cell Phone:
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| Social Security Number:
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| Email Address:
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| Do you have a valid Drivers License?:
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| State of Issue:
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| License Number:
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| Expiration Date:
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| License Class:
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| CDL:
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Yes
No
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| Total Current Points:
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| Have your driving privileges ever been suspended or revoked? :
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| If yes, Why?:
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| Are you a U.S. CItizen?:
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| If not, place of origin?:
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| Emergency Contact Information |
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| In Case of Emergency Contact:
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| Emergency Contact Address:
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| Emergency Contact City:
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| Emergency Contact State:
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| Emergency Contact Phone #:
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| Emergency Contact Relationship:
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| Military / Employment Experience |
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| Have you ever served in the armed forces?:
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| Branch:
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| Type of discharge:
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| Military Start Date:
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| Military End Date:
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| Current Occupation:
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| Employer's Name:
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| Employer's Address:
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| Employee's Supervisor:
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| Employee's Supervisor Phone #:
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| May we contact this person?:
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| Start Date:
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| End Date:
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| Criminal Information |
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| Other than minor traffic offenses, have you ever been convicted of a criminal act, or have any criminal charges pending?:
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| If yes, Please explain:
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| Education Experience |
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| Related training you bring to the company (ex. CPR):
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| List any other organizations you belong to:
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| References |
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| Provide three (3) references, not related to you. Please provide a name, address and phone number for all three:
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| Please provide the names of any fire company personnel you are acquainted with (if any):
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| Are you a member of any other Fire, EMS, or Rescue organization?:
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| Fire / Rescue / EMS Type:
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| Why are you leaving?:
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| Have you ever been rejected from this or any other Fire, EMS, or Rescue organization?:
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| If yes, explain:
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| Current Fire / EMS Certifications (If Any) |
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| CPR Expiration Date:
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| EMS Certification Level:
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| Enter EMS Certification ID #:
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| EMS Certification Expiration Date:
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Fire / Rescue Training:
Enter all current Fire / Rescue Certifications
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NIMS ICS 100:
Date Obtained
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NIMS ICS 200:
Date Obtained
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NIMS ICS 300:
Date Obtained
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NIMS ICS 400:
Date Obtained
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NIMS ICS 700:
Date Obtained
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NIMS ICS 800:
Date Obtained
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| 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. |
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| Date of Birth:
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| Why do you want to be a member of the Hampstead Fire Engine & Hose Company #1?:
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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
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| NOTE:
NO APPLICATION WILL BE ACCEPTED WITHOUT THE FIRST YEARS DUES PAID IN FULL! |
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| In order to be considered for membership you must submit a recent photo with your completed application.:
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| 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 |
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| By typing my name I am certifying that all the information is honest and correct. |
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| Signature of Applicant:
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| Signature of Parent or Guardian (If applicant is under 18):
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| Date of submission:
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10/09/2024 1458 |
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| Upon submission of this application you will be directed to our PayPal page so you may pay the $5.00 application fee. |
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Oct 11, 2024
