Your Full Name

Your Address

City

State

Zip Code

Telephone (Home)

Telephone (Cell)

Telephone (Work)

Number of Years at Residence

Residence Type

Social Security Number

Type of Membership Requested (Choose One)

List Three References with Phone Numbers

Do you understand that under New York State Law you are subject to an automatic arson background check, and that the Weedsport Fire Department will have such a check completed?

Do you object to any other type of personal background check that may be completed by this organization in reference to your character and personal past.

Do you have any limitations or disabilities that would prevent you from performing the duties of a volunteer fire person?

If yes, please provide a brief explanation.

As an active member of the department you will be entitled to certain insurances and benefits. Please identify someone other than yourself to be your beneficiary.

If accepted to the Weedsport Fire Department, I agree to abide by the Constitution and the By-Laws of the Weedsport Fire Department. I understand that I am subject to disciplinary action and/or dismissal from the department if I violate any of the above mentioned laws. I further understand that I am subject to a probationary period of six (6) months from the date of my acceptance into the department.

Date of Birth

Age

Do you understand that under New York State Law you a subject to a sex offender background check, and that the Weedsport Fire Department will have such a check completed?

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