UNION FIRE COMPANY
2055 UNION ROAD
WEST SENECA, NEW YORK 14224
APPLICATION FOR MEMBERSHIP
Date:
Personal
Name:
(Last) (First) (MI)
Address:
(Street) (Apartment)
(Town) (State) (Zip Code)
How long have you resided at the above address?
Phone #:
(Home)
Social Security #:
(Work)
Are you 18 years of age or older? Yes No DOB: / /
Do you have a valid NY
State Driver's License? Yes No License #
Employment
Are you currently employed? Yes No If Yes, complete the following:
Employer:
Address:
Position / Occupation How Long?
May we contact your employer as a reference? Yes No
Availability
Please indicate your availability to participate in normally required fire department activities (meetings, drills, and emergency calls) by marking the appropriate time periods:
Week Days: Weekends:
Days_____ Evenings_____ Nights_____ Days_____ Evenings_____ Nights_____
APPLICATION FOR MEMBERSHIP (Page 2) Name:
Previous Emergency Service Experience
Include only fire, rescue, police, or EMS agencies.
Name of Agency
Address
Contact Person Phone
List any firematic or EMS courses you have completed or certifications you possess:
(If more space is needed, please identify on attached sheet)
Additional Information
Have you ever been a member of the United States Armed Forces? Yes No
If "Yes", did you receive a dishonorable discharge? Yes No
If "Yes", give complete details on the attached sheet. Include service branch and service dates. Dishonorable discharge is not an absolute bar to membership. This and other factors will effect a final membership decision.
Have you ever been convicted or pled guilty to a felony, misdemeanor, insurance fraud, or arson?
Yes No If "Yes", give complete details on the attached sheet.
References
Please list three personal references who have known you for at least 3 years (do not include family):
1 Name Relationship
Address Phone #
2 Name Relationship
Address Phone #
3 Name Relationship
Address Phone #
Please list the names of any acquaintances that are members of this organization:
APPLICATION FOR MEMBERSHIP (Page 3) Name:
Physical
OSHA regulations require that you pass a physical examination before becoming an interior structural firefighter. The department's designated physician will provide you with a free medical examination.
Will you be willing to undergo a medical examination? Yes No
Fees
The Bylaws of Union Fire Company require an application fee of $20.00 and one year's dues of $10.00 to accompany all membership applications.
(For applicants who are transferring from another fire company, a transfer fee of $5.00 and one year's dues of $10.00 is required, provided the applicant provides a letter of recommendation from his previous company.)
"I understand that the accuracy and completeness of my statements will be relied upon by the Union Fire Company. I hereby authorize investigation of all statements contained in this application and permit the Union Fire Company to obtain any records or documents pertaining to my background and business experience. I also agree to release the Union Fire Company from any liability arising therefrom and understand that any misstatements, omissions, or false statements may be cause for dismissal."
Applicant Signature Date
Additional Information
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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 for you.
The authority to request and confirm personal information about 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 potential supervisors; and
be maintained in your personnel file (if you become a fire company member) or in our application 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 Recording Secretary of the Union Fire Company.
APPLICANT'S AUTHORIZATION FOR RELEASE OF INFORMATION
In order to conform the information I supplied on my application for membership with the Union Fire Company, I authorize all licensing agencies, educational institutions, law enforcement agencies, present and former employers, and the military services to disclose their relevant records about me to the Union Fire Company whether the information be of public, private, or confidential nature; and I release them from any liability and responsibility from doing so.
This authorization, in original copy form, shall be valid for this and any future information, reports or updates that may be requested.
I understand that this form will accompany requests for official documents and confirmations of my credentials.
Applicant Name (Please Print) Applicant's Signature Date