Membership Application

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General Information

Which position are you applying for?*

Volunteer Firefighter

Junior Member

Name*

First Name Middle Name Last Name

List any Alias and/or Maiden Names used (Required for NYS DCJS Inquiry)

Address*

Street Address: Address Line 2: City: State: Zip:

Email:*

Phone:*

Are you over the age of 18?*

Yes

Date of Birth:*

Place of Birth (City, State)*

SEX (Required for NYS DCJS Inquiry)*

Height (Ft., In.)*

Social Security Number (required for NYS DCJS Inquiry)*

Ethnicity (Required for NYS DCJS Inquiry)*

Have you ever applied to or worked for Willowvale Fire Company, Inc. before?*

Yes

When and in what capacity/position?*

Do you have any friends, relatives, or acquaintances working for Willowvale Fire Company, Inc.?*

Yes

Name & relationship to you:*

Have you ever been convicted of a criminal offense (felony or misdemeanor)?*

Yes

Please state the nature of the crime(s), when and where convicted and disposition of the case:*

Driver's License Information

Do you have reliable transportation?*

Yes

Do you have a valid driver's license?*

Yes

Driver's License Number*

Driver's License State*

Driver's License Expiration Date

Do you have a valid CDL?*

Yes

List CDL classification and any endorsements:*

Has your drivers license ever been suspended or revoked?*

Yes

Please explain:*

Education Information

Do you have a high school diploma or GED?*

High School Diploma

GED

Neither

Name and Location of high school:*

Name and Location where you obtained your GED:*

Have you completed any college or university course work?*

Yes

Please list all college coursework and/or degrees completed:

Name of College/University:	Type of Degree:	Actions

There are no Schools.

Maximum number of schools reached.

Please list below the skills and certifications you possess for the position for which you are applying:

Mililtary Service

Are/were you a member of the Armed Services?*

Yes

Are you still serving or have you been discharged?*

Still Serving

Discharged

Branch of Service:*

Current Rank:*

Rank When Discharged:*

How many years total did you serve?*

How many years have you served so far?*

Employment History

Begin with your present or most recent employer. List ALL jobs, paid or volunteer, over the last 5 years. Include any experience prior to 5 years ago that relates to the position. To add a new position to the list, click "Add Entry".

Employment

Name of Employer:	Position Title:	Actions

There are no Jobs.

Maximum number of jobs reached.

Have you ever been terminated, discharged, or resigned in lieu of termination due to misconduct or unsatisfactory service?*

Yes

Please name the employer, explain the circumstances, and date (Mo/Yr).*

Prior Fire/EMS Experience

Please list any previous Fire and/or EMS Organization Affiliation. If you have none, simply click "Next".

Employment

Agency Name:	Position:	Actions

There are no Jobs.

Maximum number of jobs reached.

Character References

List, as character references, two (2) persons you have known for at least three (3) years and who are NOT related to you

References

Name	Relationship:	Actions

There are no References.

Maximum number of references reached.

Certification and Authorization

l 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 may be rejected. or if a member, my membership and all rights and privileges of my membership may be immediately terminated. My signature on this application indicates that I have read the job description for the positions available to me and I understand that the job of a fire fighter or EMS member is physically challenging and that my membership is dependent upon my successful completion of a physical examination, and that I receive a favorable background investigation.

I authorize the investigation of all statements contained herein, and direct the custodian of any records relevant to the confirmation of these to release such information necessary for verification. I release any individual, institution. business or organization from any liability for damages, which might arise from the release of pertinent information. I have read, or have had read to me, the statements above and by my signature, agree to these provisions.

Certification and Authorization Agreement*

Yes, I agree. *

The relationship between you and the Willowvale Fire Company, Inc. is referred to as "employment at will." This means that your membership can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Willowvale Fire Company, Inc. No representative of Willowvale Fire Company, Inc. has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.

Certification and Authorization Agreement*

Yes, I understand. *

Full Name:*

Signature:*

Your Name
Your Name
Your Name

Today's Date:*

Parent/Legal Guardian Name:*

Parent/Guardian Signature:*

Your Name
Your Name
Your Name

Today's Date:*

Application Fee

Non-Refundable Application Fee:*

Price:

Credit Card*

Cardholder Name

Card Details