Application for Membership - Newburgh Volunteer Fire Department

	Newburgh Volunteer Fire Department

	Application for Membership

This Application is the first step in seeking membership with N. V. F. D. There are three (3) steps in gaining membership with the fire department.

1) Complete this application in full, return to the Newburgh Fire Department
2) A membership committee chairperson will contact you for an interview
3) Applications will be voted on by the members of the department

Name: (Last) (MI) (First)
Social Security No.
Current Address:
Previous Address:
City: State: Zip:
Home Phone: Evening Phone:
Email:
Date of Birth: month / day / year

Do you live in the town or township: Town Township
Hours available for fire runs:

Sex:Male   Female    Marital Status:
Height: Weight:

Spouse Name:
Present Employer:
Employer Address:
Employer Phone Number: Length of Employment:
Type of job:
Hours you work:
Previous Employer:
Previous Employer Address:
Reason for leaving:
Last grade of education completed:
Do you have any felony or misdemeanor convictions or any pending? Yes   No
If yes, please explain:

Have you ever been convicted of a crime in the last 10 years? Yes   No
If yes, please explain:

Have you committed any traffic violations in the last three years? Yes   No
If yes, list violations and dates:

Do you have any physical handicaps: Yes   No
If yes, please explain:

Have you had any serious illness in the last five years? Yes   No
If yes, please explain:

Are you allergic to any medication: Yes   No

In case of emergency, contact:
Telephone: Address:
Family physician: Physician's Telephone:
Blood type:
Your physical condition: Good Fair Poor
Would you agree to a physical if required: Yes No

List two (2) personal references name and addresses:
1. Name: Address:
2. Name: Address:

I do hereby submit my application seeking membership with the Newburgh Volunteer Fire Department as an active member to aid in the prevention and extinguishment of fires, to protect lives and property.

I certify that the facts in this application are true and complete to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained therein and the references and employers listed above to give any and all information concerning my previous employment and any pertinent information that may result from the utilization of such information.

Today's Date:
Your Signature Name:
Yes, I Agree

This form may be submitted via email, printed and faxed to (812)853-0489 or you may print it, fill in and bring to 540 State Street Newburgh, IN 47630. All applications are kept on file for six (6) months and are reviewed for all vacant positions for which an applicant is qualified. Newburgh Fire Department is always accepting applications.