New Salem Volunteer Fire Dept

Member Application

Application

Your Full Name

Your Address

City

State

Zip Code

Cell Phone

Home Phone

Email Address

Volunteer or Paid

Birthday

Marital Status

Height

Weight

Physical Condition

Blood Type

Allergies

List Immediate Family Members

Have you ever been compensated for an industrial injury?

Have you ever been convicted of a crime or traffic violation?

If Yes, please enter date of crime or violation.

Have you ever been addicted to drugs or alcohol?

If Yes, please enter date.

Name of High School

Did you you receive a Diploma or GED?

Name of College

Please select what you receive upon graduation.

List any Fire Departments you are or have been affiliated with.

List any prior experience and any special training in Firefighting or Rescue work.

List 3 references with phone numbers.

List 2 previous employers.

Do you reside in the New Salem Fire District?

Do you have a current North Carolina Driver's License

I UNDERSTAND THAT FALSE STATEMENTS ON THIS APPLICATION WILL BE CONSIDERED SUFFICIENT CAUSE FOR DISMISSAL AND DO FURTHER AGREE, IF ACCEPTED I WILL ABIDE BY THE RULES AND POLICIES OF THE ORGANIZATION.

I UNDERSTAND THAT THE SAFETY AND SECURITY OF THE MEMBERS OF OUR COMMUNITY ARE OF THE UTMOST IMPORTANCE AND AGREE TO BE SUBJECT AT ANY TIME TO A BACKGROUND CHECK INCLUDING BUT NOT LIMITED TO CRIMINAL AND MOTOR VEHICLE RECORDS.

I AUTHORIZE NEW SALEM VOLUNTEER FIRE DEPARTMENT, INC. TO OBTAIN ANY ADDITIONAL INFORMATION RELATIVE TO MY APPLICATION. I UNDERSTAND THAT UPON APPROVAL BY THE BOARD OF DIRECTORS, I WILL BE IN A PROBATIONARY AND TRAINING PERIOD FOR SIX MONTHS. AT THE END OF THAT TIME, THE BOARD OF DIRECTORS WILL MAKE A FINAL DISPOSITION ON THIS APPLICATION.