MEMBERSHIP APPLICATION

Date:
Position applying for:
Person who sponsored or referred you:
PERSONAL INFORMATION
Name:
E-mail Address:
Social Security Number:
Present Address:
City:
State:
Zip:
Years at current address:
Phone Number:
United States Citizen?
Date of Birth:
Place of Birth:
Height:
Weight:
Sex:
Valid New Jersey driver's license?
Driver's license number:
Are there any restrictions on your driver's license?
If yes, please explain:
Are there any points on your driver's license?
If yes, please explain:
EMPLOYMENT HISTORY
Employer #1:
Business Address:
Business Phone Number:
Immediate Supervisor:
Employment Dates: From: To:
Position held:
May we contact employer?
If not, please explain:
 
Employer #2:
Business Address:
Business Phone Number:
Immediate Supervisor:
Employment Dates: From: To:
Position held:
May we contact employer?
If not, please explain:
 
Employer #3:
Business Address:
Business Phone Number:
Immediate Supervisor:
Employment Dates: From: To:
Position held:
May we contact employer?
If not, please explain:
GENERAL INFORMATION
Have you ever been a firefighter?
If yes, please state where, how long and list the name and number of your chief:
List all skills, qualifications or interests that you feel are related to the position you are applying for:
What is your physical condition?
Have you been ill or hospitalized for any reason within the past 5 years?
If yes, please give details:
Are you currently involved in litigation for compensation injuries?
If yes, please give details:
Do you have any handicaps that would prevent you from performing certain duties?
If yes, please give details:
Have you ever been convicted of a crime?
If yes, please give details:
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
Name:
Present Address:
City:
State:
Zip:
Phone Number:
Relationship:
EDUCATION INFORMATION
High School Name:
High School Address:
Dates attended: From: To:
Did you graduate?
If no, please give details:
Did you attend college?
If yes, name and address of college:
Dates attended: From: To:
Did you graduate college?
MILITARY EXPERIENCE
Have you ever served in the military?
If yes, what branch?
Dates served: From: To:
Highest rank:
Type of discharge:
REFERENCES (NOT RELATED TO APPLICANT)
Reference 1:
Address:
City:
State:
Zip:
Phone Number:
Occupation:
Aquainted for how many years:
 
Reference 2:
Address:
City:
State:
Zip:
Phone Number:
Occupation:
Aquainted for how many years:
 
Reference 3:
Address:
City:
State:
Zip:
Phone Number:
Occupation:
Aquainted for how many years:

BY CLICKING THE "APPLY" BUTTON, I AGREE TO THE FOLLOWING:

PLEASE READ CAREFULLY: AUTHORIZATION FOR REFERENCE CHECK

I DO HEREBY CERTIFY THAT THE FOREGOING STATEMENTS THAT I HAVE MADE ARE TRUE AND ARE INTENDED TO BE USED BY THE BOARD OF FIRE COMMISSIONERS FOR FIRE DISTRICT #1, TOWNSHIP OF BRICK, FOR PURPOSES OF EVALUATING MY APPLICATION FOR THE POSITION OF FIREFIGHTER FOR HONESTY AND ACCURATENESS. THE STATEMENTS HAVE BEEN MADE WITHOUT FRAUD AND KNOWING FULL WELL THAT THE BOARD OF FIRE COMMISSIONERS FOR FIRE DISTRICT #1 RELY ON THEM AS TRUE. I AM AWARE THAT IF ANY OF THE FOREGOING STATEMENTS MADE BY ME ARE FOUND TO BE WILLINGLY FALSE, THAT I AM SUBJECT TO IMMEDIATE DISMISSAL FROM BRETON WOODS FIRE COMPANY #1.

TO ASSIST IN EVALUATING MY EMPLOYMENT QUALIFICATIONS, I AUTHORIZE THE BRICK TOWNSHIP FIRE COMMISSIONERS FOR FIRE DISTRICT #1 TO REQUEST AND RECEIVE ANY INFORMATION CONCERNING ME. INCLUDING, BUT NOT LIMITED TO, REPORTS FROM ANY PERSONS, DOCTORS, SCHOOLS, LICENSING AGENCIES, LAW ENFORCEMENT AGENCIES, AND FROM ANY OF MY PREVIOUS EMPLOYERS.

I ALSO AUTHORIZE ANY OF THE AFOREMENTIONED PARTIES TO FURNISH THE COMMISSIONERS WITH ALL INFORMATION CONCERNING ME. I FURTHER RELEASE ALL PARTIES AND THE BRICK TOWNSHIP BOARD OF FIRE COMMISSIONERS FOR FIRE DISTRICT #1 FROM ANY AND ALL LIABILITY AND RESPONSIBILITY ARISING OUT OF SUCH INFORMATION.