Phone# 410-242-1093 APPLICATION FOR MEMBERSHIP (All questions must be answered; incomplete applications will not be accepted) Please print all information clearly : Demographic/Personal Background & History Full Name: Social Sec#: of Birth: Gender: Male Female Marital Status: Single Married Separated Divorce Height: Weight: Eye Color: Hair Color: Phone#: E-Mail: Previous: Place of Birth: (If less than five (5) years, please complete previous below). Duration: Do you, or have you ever, used an alias? YES If yes, give name(s) and reason: NO Are you a current licensed operator of a motor vehicle in Maryland? YES NO If yes, please list type(s) of license (class): Driver s License Number: (Please attach copy of driving record) Has any license heretofore been issued to you in any other state or district? YES NO If so, where? Has any license issued to you ever been suspended or revoked? YES NO If yes, please specify/explain: of reinstatement: Are there any restrictions? YES NO Do you have any physical or mental defects or deformities of which you are aware that would in any way interfere with the proper orientation and control of a motor vehicle or the duties of a volunteer firefighter or ambulance attendant? YES NO If yes, please describe: If yes, please attach a certificate from your doctor stating you can perform the required duties. Received Voted In Rejected LOSAP#.
Employment/Military Background & History Present Occupation: Name of Employer: Duties: Length of Employment: Supervisor: (Employer will not be contacted) Phone#: Have you ever served in the Armed Forces or Militia of the United States of America? Yes No Branch of Service: From: To: Type of Discharge: Honorable Medical Undesirable Dishonorable Have you ever been a member of this Association or any other volunteer fire departments of rescue groups? YES NO If yes, please provide particulars (name and address of former department(s) : Reason for leaving: Criminal Background Information Have you ever been convicted of a criminal offense, since your eighteenth birthday, where you were represented by an attorney or waived your right to an attorney? YES NO If yes, please explain, giving the date, jurisdiction, a brief description of the charge, and the outcome including PBJ: Is there anything in your background that would prevent you from fully performing the duties of a firefighter / ambulance attendant? YES NO Is there anything in your background that would bring disgrace and/or dishonor to this department? YES NO Additional I fully understand that upon becoming a member of the Lansdowne Volunteer Fire Department, I am required to work fundraising activities. YES NO 2
Briefly explain why you would like to become a member of this Association. Please be sure to submit a copy of any training that you have from your employer that can be used toward your certification in the Emergency Services (i.e. EMT, IV Tech, Hazardous Materials, etc.) I, the undersigned, understand that I am on a one-year probationary period. I also understand that during this probationary period I am not eligible to hold office, either elected or appointed. I, the undersigned, understand that false statements to any of the foregoing herein, under law, constitute perjury and that detection of such will result in rejection of application for membership, or dismissal from the Association. All of the foregoing statements are true and correct to the best of my knowledge, information, and belief. I, the undersigned, waive my rights under the Right to Privacy Act in regard to any investigation resulting from this application for membership. I understand that the information contained herein and any information developed from such investigation will be held in the strictest confidence. ALL DOCUMENTATION MUST BE SUBMITTED WITH THIS APPLICATION. APPLICANT MUST BE PRESENT AT THE MEETING WHEN THE APPLICATION IS PRESENTED. REGULAR MEETINGS ARE HELD ON THE SECOND MONDAY OF EACH MONTH. Signature of Applicant (if under 18 years of age, approval of parent/guardian) Signature of Sponsor Signature of Parent/Guardian Current Baltimore County LOSAP Number: 3
APPLICATION CHECKLIST PICK UP APPLICANT NAME: EMAIL ADDRESS: PHONE#: GIVEN BY: RETURNED BACKGROUND INVESTIGATION: INVESTIGATOR: INTERVIEW: INTERVIEW PANEL: DATE DRUG TEST FORM PROVIDED: DRUG TEST ISSUED BY: RESULTS: RECOMMENDATION FOR MEMBERSHIP: SIGNED: MEMBERSHIP VOTE ACCEPTED REJECTED SIGNATURE: 4
CONTACT SHEET Contact Information Name: Home Phone: Cell Phone: E-Mail Contact Preferences Availibility I prefer to be contacted by Home phone Cell phone Email During which hours are you available for volunteer assignments? Weekday mornings Weekend mornings Weekday afternoons Weekend afternoons Weekday evenings Weekend evenings Weekday overnights Weekend overnights Interests Tell us in which areas you are interested in volunteering Administration EMS (ambulance) Fire Fundraising Special Skills or Qualifications Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports. 5