application

APPLICATION FOR MEMBERSHIP

To the officers and members of the Newland-Wood Fire Company:

I wish to obtain active membership in the Newland-Wood Fire Company of the Stillwater Fire Department. I have answered all of the questions on this application to the best of my ability. I attest by my signature below that all of the information on this application is true.

(Please Print Information)

Membership Status: Active Firefighter Junior Firefighter Social/Support Class

Name: __________________________________________________________________

(Last) (First) (M.I.)

Address: ____________________________________________________________

(Street) (City) (State) (Zip Code)

Contact Numbers: _____________________________________________________

(Home) (Cell) (Other)

How long have you resided at the above address? Years: ________ Months: ________

How long have you resided in New York State? Years: ________ Months: ________

Are you 18 years of age or older? Yes: ____ No:____ If NO, state your age: ____

Is additional information about a change in your name or your use of an assumed name or nickname necessary to enable a check on your eligibility for membership?

Yes: ____ No: ____ If YES, explain: ________________________________________________________________________

_______________________________________________________________________________________________________

Are you currently employed? Yes: _______ No: _______

If YES, please give employer information below. May we contact your employer as a reference? Yes: ______ No: _______

Name of Company: _______________________________________________________

Address: ______________________________________ Telephone: _________

Do you have a valid New York State Drivers License? Yes: _______ No: _______

Please indicate your availability to participate in normally required fire department activities (meetings, training drills, emergency calls):

Week Days: Days: _______ Evenings: _______ Nights: _____

Weekends: Days: _______ Evenings: _______ Nights: _____

Previous emergency services experience (include only fire, rescue, police, or EMS agencies):

Name of Agency: ___________________________________________________

Address: __________________________________________________________

Contact Person: ____________________________ Telephone: ______________

Have you ever been a member of the United States Armed Forces? Yes: __ No: ___

If yes, did you receive a dishonorable discharge? Yes: __ No: ___

Note: Dishonorable discharge is not an absolute bar to membership. This and other factors will effect a final membership decision.

Please provide service branch and dates: _________________________________

Have you ever been convicted or pled guilty to a felony, misdemeanor, insurance fraud, arson, or a reduction of these offenses?

Yes: ___No: ___ If yes, please provide further details:_____________________________________________________

________________________________________________________________________________________________

Please list three personal references, other than members of this organization, who you have known for at least three years:

Name: _________________________ Telephone #: ______________

Address: __________________________________________________

Name: _________________________ Telephone #:_______________

Address: ___________________________________________________

Name: _________________________ Telephone #: _______________

Address:____________________________________________________

Please list the names of any acquaintances that are members of this organization:_______________________________________________

___________________________________________________________________________________________________________

OSHA regulations require that you pass a physical examination before becoming an interior structural firefighter. The department’s designated physician will provide you a free medical examination. Will you be willing to undergo a medical examination?

Yes: _______ No: _______

Within the Freedom of Information Law, all information contained/or obtained herein will remain confidential and will be used only for internal membership processing.

In witness whereof, this application has been subscribed this __________ day of ______________, 20____ by the undersigned applicant who

affirms that the statements made herein are true under penalties of perjury.

Applicant Signature: ____________________________________________________

Parent/Guardian Signature (if 16-18 years of age): ____________________________

Witnessed By: _____________________________________ Date: ___/___/_____

Privacy Notification

Section 94 of the Public Officers Law (Personal Privacy Protection Law) requires that you be notified of the following facts when information which will be maintained in a record system is collected from you.

The authority to request and confirm personal information on you is found in Article 6 of the Executive Law.

The information obtained will:

Be used to determine your qualifications for the position for which you are applying;

Be released to the fire chief and your personal supervisors; and

Be maintained in your personnel file (if you become a fire company member) or in our resume file for six months (if you are not a fire company member).

Failure to provide the information or authorization will result in your application not being considered for membership.

The information will be maintained by the secretary of the Newland-Wood Fire Company at 1 School Street, Stillwater, New York 12170 (518-664-3716).

Department Disclaimer:

The information presented on this application will be reviewed by the fire company at the next regularly scheduled monthly meeting. At that time the application will be tabled for 30 days to allow for a further investigation of the applicant. That investigation consists of a meeting between the company trustees and the applicant; a license check on the applicant’s driver’s license will be completed by the Village of Stillwater Clerk; and an Arson Background Check will be completed by the Saratoga County Sheriff’s Department. Following the 30 days of review, department members will vote to approve or not to approve the membership application at their next regularly scheduled meeting. If approved the fire chief will present the application to the Village of Stillwater Board of Trustees at their next regular meeting. At that time, with final approval from the Board of Trustees, the fire chief or secretary will notify the applicant of his acceptance into the fire department.

Secretary’s Endorsement:

This application accompanied by the initiation fee of $10.00 was read at the regular meeting held of the ____________ day of __________, 20_______. The prospective member, being in good standing, was referred to the trustees for approval.

Trustees Report:

The trustees report that they have inquired into the character and competence of the above candidate and have recorded their comments below.

Trustee _________________________ ACCEPT REJECT

This application was read and voted upon at the regular meeting held on _________day of ___________, 20_____. The candidate was ACCEPTED/REJECTED for membership by the members present.

Secretary’s Signature: __________________ Date: ___________