THE MANCHESTER FIRE ENGINE AND HOOK AND LADDER CO., NO.

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1 THE MANCHESTER FIRE ENGINE AND HOOK AND LADDER CO., NO. 1 P.O. Box Manchester, MD Fire Calls: 911 Meeting Night: First Tuesday of each month Membership Fee: $5.00 / Year Date Application for the following type of Membership: FIRE EMS ASSOCIATE FIRE & EMS Applicant Name (Last) (First) (MI) Current Address Apt. # City State Zip Code Telephone Numbers: Home Work How long at Current Residence Previous Address How Long City State Zip Code Social Security Number Drivers License Information: State of Issue Soundex Number Class Expiration Date Total Current Points Have your driving privileges ever been suspended or revoked? If so, why? In what State? Date of Birth Age Place of Birth Sex Race Single Married Divorced Number of Dependents Maiden Name (If Applicable) Are you a U.S. Citizen? If not, place of origin Any Alias or Nick-Names If yes, list any and all names In case of Emergency, contact Address Telephone Number Relationship

2 2 Have you ever served in the Armed Forces? Branch Type of Discharge Dates Served Have you ever been rejected for duty in the Armed Forces? If so, give reasons Highest Education Attained (Circle One): GED College Name and Address of last Education Institution Date of Graduation Degree Attained Current Occupation How long employed? Employer s Name Employer s Address Contact Person Work Telephone Number Dates of Employment: From To Other than for Traffic Offense, have you ever been convicted of a criminal act or any criminal charges pending? If so, provide all necessary information General Medical Information: Height Weight Color Eyes Color Hair Vision / Is vision corrected by glasses or contacts? Blood Type Are you presently active in a Blood Donor Program? If so, list same Are you presently on any medications? If so, what kind Do you have or have ever had any of the following conditions? If so, please explain in the comment section below. Allergies Yes No Allergic to any Medication Yes No Mental or Emotional Problems Yes No Alcohol or Substance Abuse Yes No Physical Impairments Yes No

3 3 Hearing Impairments Yes No Coronary Problems Yes No Diabetes Yes No Convulsions or Seizures Yes No Respiratory Diseases Yes No Any other Medical or Physical problems not covered above? If so, note in comment section. Comments Date of last complete Physical Physician s Name Office Location Office Telephone Number References: Give the names of three (3) persons not related to you, whom you have known for at least three (3) years. Name Address Telephone Give the names of two (2) members of the Manchester Volunteer Fire Department you are acquainted with (if any). General Information: Are you presently a member of any Fire, EMS or Rescue Department? Yes No Career Volunteer If yes, list company names: Reason(s) for Leaving: Have you ever been rejected, suspended or expelled from this or any other Volunteer Fire, EMS or Rescue Company? If yes, explain: READ THE FOLLOWING STATEMENT CAREFULLY BEFORE SIGNING: I HEREBY AUTHORIZE THE MANCHESTER VOLUNTEER FIRE COMPANY TO INVESTIGATE ALL STATEMENTS CONTAINED IN THIS APPLICATION. TO THE BEST OF MY KNOWLEDGE, ALL STATEMENTS AND ANSWERS WHICH I HAVE GIVEN ARE TRUE AND CORRECT. I

4 4 UNDERSTAND THAT MISREPRESENTATION OR OMISSION OF FACTS MAY RESULT IN NULLIFICATION OF THIS APPLICATION OR SUBSEQUENT MEMBERSHIP BASEED UPON ITS CONTENTS. SIGNATURE DATE I, HEREBY AUTHORIZE MANCHESTER VOLUNTEER FIRE COMPANY TO OBTAIN A CRIMINAL RECORD REPORT THROUGH MARYLAND STATE POLICE AND THROUGH THE FEDERAL BUREAU OF INVESTIGATION (NATIONAL CRIMINAL INFORMATION CENTER). SIGNATURE DATE **NOTE** A DRIVER S LICENSE RECORD WILL ALSO BE OBTAINED. IF APPLICANT IS UNDER 18 YEARS OF AGE, A WORK PERMIT WILL BE REQUIRED OF THE APPLICANT. (CAN BE OBTAINED IN SCHOOL GUIDANCE OFFICE.)

5 5 PARENTS OR GUARDIAN'S CONSENT FOR APPLICANTS UNDER 18 YEARS OF AGE. I / WE, BEING THE PARENTS OR GUARDIAN OF THE APPLICANT WHOSE NAME APPEARS BELOW, DO HEREBY GIVE MY CONSENT FOR HIM TO JOIN THE MANCHESTER VOLUNTEER FIRE CO. I ALSO UNDERSTAND THAT BY BEING A MEMBER OF THIS COMPANY, THAT HE IS ENTITLED TO ANY INSURANCE BENEFITS THAT MAY LEGALLY BE CLAIMED AS A RESULT OF ANY ACCIDENT WHILE ON FIRE DUTY. Name of Applicant Signature of Parent/Guardian if under age 18 Date Why would you like to be a Member of the Manchester Volunteer Fire Department? I, the undersigned, make application to become an active member of the Manchester Volunteer Fire Department. I, the undersigned, agree to submit to a complete physical, if deemed necessary by the Membership Committee of the Fire Company. This can be required at any time during your membership. I, the undersigned, do promise to abide by all of the laws and rules regulating the Manchester Volunteer Fire Department, either in effect or to become effective by vote of the membership. I, the undersigned, understand that the Department, at its expense, shall undertake an investigation into my background and that I will be required to appear before the Applicant Investigation Committee. I, the undersigned, understand that should my application for membership be accepted by the members of the Manchester Volunteer Fire Department, I shall be on a 365 day probationary period. At the end of such period, I understand I will be voted on again by the membership to become a regular member of the department. I also understand that to be considered for permanent membership, I must accumulate 25 LOSAP points within my probationary period. I, the undersigned, understand that false statements to any of the foregoing herein, under the law constitutes perjury and the detection of such falsity will result in rejection of this application for membership, or immediate dismissal from the Manchester Volunteer Fire Department. I further certify that all answers to all questions on this application are true and correct. As an express condition of membership, I, the undersigned, hereby freely and voluntarily consent to examination by polygraph, at the expense of the Manchester Volunteer Fire Department, at any time while a member of the same, when required by the Board of Directors and approved by the membership. I, the undersigned, enclose $5.00 for the initiation fee, also $ annual dues. I understand that the initiation fee is not refundable, and that any dues paid once I have been accepted for probationary membership are not refundable. Sponsors: (Must be a M.V.F.D, Member) Signature of Applicant Signature of Parent or Guardian if Applicant is Dues Received by Date under the age of 18

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