THE MANCHESTER FIRE ENGINE AND HOOK AND LADDER CO., NO. 1 P.O. Box 416 - Manchester, MD 21102 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 _______________________________________________________________ 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): 10 11 12 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 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 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.) 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 Dues Received by ___________ Date _______ Applicant is under the age of 18