Pvfd application

Pine Village Community
Volunteer Fire Department, Inc.

New Membership Application

Applicant Infomation

Applicant Full Name *

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Dear Prospective Member: Thank you for your interest in becoming a member of the Pine Village Community Volunteer Fire Department, Inc. We strive to be a proud and well-respected part of this community. The following items are just a few points to consider before you decide to become a member of this Fire Department. 1. The Pine Village Community Volunteer Fire Department, Inc. provides emergency response (fire, motor vehicle accidents, and first response emergency medical services) to the Town of Pine Village and surrounding townships covering approximately 110 square miles. 2. You will be expected to attend department meetings, which are held on the second Wednesday of each month. 3. Training is very important in this department. We invest a great deal of time in training our new and current members and we need total commitment from them. Normal training is held the third Wednesday night from 7PM to 9PM. With additional training scheduled on an as needed basis. 4. A six (6) month probationary period is required for all new members. An additional period may be required in the event that your minimum requirements have not been satisfied. 5. You should discuss this commitment that you are thinking about making with your immediate family. Becoming a volunteer firefighter can affect your lifestyle, and you and your -family should be prepared for this challenge. Thank you and we look forward to processing your application to become a member of the Pine Village Community Volunteer Fire Department. Regards, Cody Craigin Chief Pine Village Community Fire Department, Inc.

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Personal Information

last name

(Last Name)

First Name

(First Name)

middle initial

(Middle Initial)

address

(Address)

apt #

(Apt#)

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city/town/village

(City/Town/Village)

state

(State)

zip code

(Zip Code)

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Telephone:

home phone

Home Phone:

cell phone #

Cellular Phone:

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Email *

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How long have you resided at the above address?

Years

Years:

months

Months:

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How long have you resided in the State of Indiana:

Years

Years:

months

Months:

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Date of Birth:

date of birth

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Is additional information about a change in your name or your use of an assumed name or nickname necessary to enable a check of your eligibility for membership?

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If yes - please explain

if yes-please explain

Are you currently employed?

employed

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May we contact your employer as a reference?

employer reference yes no

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if yes, give employer information below.

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Name of Company:

company name

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Address:

address

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Telephone:

telephone

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Position Held

position held

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Do you currently have a valid Indiana State Driver's License?

drivers license yes or no

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11.

Please indiate your availability to participate in normally required fire department activities ( alarm response, drills, meetings)

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Please check appropriate time periods

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Weekdays:

Days
Evenings
Nights

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Weekends:

Days
Evenings
Nights

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Personal Information

12.

Have you previously been a member of a Fire Department?

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If yes, please provide name and address of agency

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Name of Agency:

agency name

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Address:

address

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Telephone:

telephone

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Contact Person:

contact person

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Title:

title

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13.

Plaese list any Public services Courses you have completed:

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Course Name

Year Completed

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1. Course Name

1. Year Completed

Year Completed

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course name 2

2. Course Name

2 year

Year Completed

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3 course name

3. Course Name

3 year

Year Completed

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4 course name

4. Course Name

4 year

Year Completed

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5 course name

5. Course Name

5 year

Year Completed

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6 course name

6. Course Name

6 year

Year Completed

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7 course name

7. Course Name

7 year

Year Completed

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14.

Please List any Emergency Medical training you have completed:

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Course Name

Year Completed

Is Certification Current

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1 Course Name

1. Course Name

1 Year completed

Year Completed

Is Certificaton Current

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2 Course Name

2. Course Name

2 Year completed

Year Completed

is cert current

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3 Course Name

3. Course Name

3 Year completed

Year Completed

is cert current

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4 Course Name

4. Course Name

4 Year completed

Year Completed

Is cert current

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5 Course Name

5. Course Name

5 Year completed

Year Completed

Id cert current

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6 Course Name

6. Course Name

6 Year completed

Year Completed

is cert current

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Being a member of this department has many facets. This section is to give the department a general idea of your insterest. As training progresses, it is understood that these interest may change. Please check all that apply.

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Fire Operations:

Fire Operations

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Rescue Operations

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Emergency Medical Services

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Parades

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Commitee Work

Committee Work

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16.

Have you ever been convicted of or pled guilty to a felony, misdemeanor, insurance fraud, arson, or a reduction to one of these offenses? If Yes, please give details in the section entitled Additional Information.

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Personal Information

17.

Please list the names of any acquaintances that are members of this department.

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18.

OSHA and State regulations require you to pass a physical examination before becoming a firefighter. Will you be willing to undergo a medical examination?

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ADDITIONAL INFORMATION

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Please use the below space to include any additional information deemed pertinent to your application for membership.

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Personal Information

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Criminal Background Check

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Please write legibly or your application will not be processed

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Name:

Last Name

(Last Name)

First Name

(First Name)

Middle Initial

(Middle Initial)

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Also Known as:

(Known As)

N/A:

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Address:

(Address)

Apt #

(Apt #)

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City:

(City)

State

(State)

Zip Code:

(Zip Code)

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Phone Number:

Date of Birth:

Social Security #:

Indiana Driver's License#:

I hereby authorize the Pine Village Community Volunteer Fire Department, Inc. to initiate a criminal background check and a Department of Motor Vehicle history check at any time for any reason:

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Applicant's Signature:

Date:

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This background check may be completed by the Indiana State Police and / or the Warren County Sheriff Department.

Background Findings:

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Police Department Signature:

Police Departments Signature

Date:

Date

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FireDeptartment Use

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The above applicant is:

Applicant approved / disapproved

APPROVED
DISAPPROVED

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Reason for determination:

Fire Department Signature:

Fire Department Signature

Date:

Date

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Applicant Statements

Please Read

WITHIN THE FREEDOM OF INFORMATION LAW, ALL INFORMATION CONTAINED/OR OBTAINED HEREIN WILL REMAIN CONFIDENTIAL AND WILL BE USED ONLY FOR INTERNAL MEMBERSHIP PROCESSING. "I herby make application to become a member of the Pine Village Community Volunteer Fire Department, Inc., I promise cheerful compliance to all laws, rules, and regulations of said department and pledge myself to respond to alarms and attend at minimum thirty-three (33) percent of dispatches and meetings. I understand that I will undergo a probationary period of six (6) months after becoming a member and thereafter live up to all obligations of an active member. I also pledge strict and prompt obedience to the orders of the chief and his duly constituted assistants when at fire or activities. I will also attend required mandatory Firefighting training during my first six (6) months of membership".

IN WITNESS WHEREOF, THIS APPLICATION HAS BEEN SUBSCRIBED THIS ___________DAY OF_________, 20_______. BY THE UNDERSIGNED APPLICANT WHO AFFIRMS THAT THE STATEMENTS MADE HEREIN ARE TRUE UNDER THE PENALTIES OF PERJURY.

Day:

Day

Month

Year (2 digits)

Year

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Applicant Signature:

Applicant Signature

Date:

Date

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If you are under 18 years of age, this application must also be signed by a parent or legal guardian.

Parent/Legal Guardian Signature:

Parent/Legal Guardian Signature

Date:

Date

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Applicant Statements

THIS SHEET FOR FIRE DEPARTMENT USE ONLY

Application Recieved (date):

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Criminal Background Check (date):

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Notification to Applicant for Interview Date:

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Interview Date:

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Membership Approval (at least three fire officers must be present to conduct interview)

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Sign:

Sign

Date:

Date

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Sign:

Sign

Date:

Date

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Sign:

Sign

Date:

Date

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Sign:

Sign

Date:

Date

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Sign:

Sign

Date:

Date

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Letter sent to applicant with Physical Authorization Letter (date)

Date

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Physical Results Received (date):

Date

Pass
Fail

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Chief Signature to confirm receipt:

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Applicant Notified on Membership Approval:

Applicant Notified on Membership Approval: (date)

Date

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Applicant Obligated: (Meeting Date):

Date

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Department ID Assigned:

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Member information entered into database (date):

Date

Pine Village CommunityVolunteer Fire Department, Inc.

New Membership Application

Pine Village Community
Volunteer Fire Department, Inc.