Join | Hillcrest Volunteer Fire Department

Date:

First Name:

Middle Initial:

Last Name:

Date of Birth:

Street Address:

City/Town:

State:

ZIP Code:

Years at Address:

Phone Number:

Place of Birth:

Social Security #:

Height:

Are you Currently Employed:

Yes

No

May We Contact your Employer as a Reference:

Yes

No

Not Employed

Name of Employer:

Employer Telephone Number:

Do you have a NYS Driver's License:

Yes

No

Are you 18 years of age or older:

Yes

No

Applicants under 18 years old require parental consent to become an active JR. Firefighter.

If you live outside the Hillcrest Fire District, state your reason for applying to Hillcrest:

Type of Membership Application:

Secondary Membership Classification:

Previous Emergency Service Expierience: ( Include only Fire, Rescue, Police, EMS )Include agency name, address, contact person, telephone number.

Have you been denied membership to another fire department:

Yes

No

If you answered yes to the previous question, please explain why in the box below.

Have you ever been a member of the U.S. Armed Forces:

Yes

No

Did you receive a dishonorable discharge:

Yes

No

If yes to the previous question, please give complete details, including service branch and service dates:

Have you ever been convicted or pled guilty of a Felony/Misdemeanor, Arson, Insurance Fraud or to a reduction of one of these offenses:

Yes

No

If yes to the previous question please give additional details below:

References: ( List up to 3 references not related to you and preferably not a member of HIllcrest Fire Department that you have known for over 2 years. For personal references, include their names and Tel numbers )

Reference #1:

Name:

Telephone Number:

Reference #2:

Name:

Telephone Number:

Reference 3:

Name:

Telephone Number:

OSHA regulations require that you pass a physical examination before becoming an active firefighter. The Fire District will provide you with a free yearly medical examination.

Are you willing to undergo a yearly medical examination from the Fire District designated provider/Physician?

Yes:

No:

Additional Information:

Privacy Notification: Section94 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 about you is found in Article 6 of the Executive Law. The information obtained will: (1) Be used to determine your qualification for the position for which you are making an application: (2) Be released to the Fire Chief and your potential supervisors: (3) Be maintained in your personnel file (if you become a fire department member) or in our temporary file for 6 months (if you are not a fire department member). Failure to provide the information requested or the authorization requested will result in your application not being considered for membership. Failure to provide truthful answers may result in your application not being considered for membership. This information will be maintained by the Fire Chief at 145 Pruyn Hill Road Mechanicville, NY 12118 Tel (518) 664-3434 Applicants Authorization for Release of Information: In order to confirm the information I supplied on my application for membership in the Hillcrest Fire Department, I authorize all licensing agencies, educational institutions, law enforcement agencies, present and former employers and the US military services to disclose their relevant records about me to the Hillcrest Fire Department and or the Halfmoon Fire District #1, 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 written requests for official documents and confirmations of my credentials.

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Hillcrest Vol. Fire Department

Mechanicville, NY

Join the Hillcrest Volunteer Fire Department and Help your Community

Hillcrest Fire Department Membership Application