Volunteer Firefighter - Membership Application - New Hartford Fire Department

Are you 18 years of age or older?*

Yes

You must be 18 years of age or older to apply to be a volunteer firefighter with the New Hartford Fire Department.

However, if you are between the ages of 16-17, we invite you to check out our Restricted Member Program by clicking here.

Name

First Name: Middle Initial: Last Name:

Address

Company Address: Address Line 2: City: State: Zip:

Email:*

Phone:

How long have you lived at the above address?

How long have you resided in New York State?

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

Please explain:*

Please list three personal references, other than members of this organization, who have known you at least three (3) years:

Reference 1

REFERENCE #1:

First Name: Last Name:

Address

Street Address Address Line 2 City State ZIP Code

Phone

Reference 2

REFERENCE #2:

First Name: Last Name:

Address

Street Address Address Line 2 City State ZIP Code

Phone

Reference 3

REFERENCE #3:

First Name: Last Name:

Address

Street Address Address Line 2 City State ZIP Code

Phone:

Applicant’s Authorization for Release of Information

In order to confirm the information I supplied on my application for membership with the New Hartford Volunteer Fire Department, I authorize all licensing agencies, education institutions, law enforcement agencies, present and former employers, and the military services to disclose their relevant records about me to the New Hartford Volunteer Fire Department whether the information be public, private or confidential nature; and I release them from 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.

Name

Applicant First Name: Applicant Middle Initial: Applicant Last Name:

Signature:

Today's Date:

Application Fee:

Price:

Payment Method*

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Volunteer Membership Appllication

Please complete the entire membership application below. Incomplete applications will not be considered.

Reference 1

Reference 2

Reference 3

Applicant’s Authorization for Release of Information