Brooklin Volunteer Fire Company · Brooklin Fire Department Member Application

Thanks very much for your interest in the Brooklin Fire Department!

Please complete all fields in this application. We will be in touch shortly after you submit the form.

If you would like to discuss before completing the application, call:

Chief Sam Friend at 669-2469

or

Assistant Chief Tommy Morris at 619-3360

Name

*

Prefix

First Name

Last Name

Suffix

Middle / Maiden name

Enter your middle or maiden name if you have one

Preferred nickname

Enter your preferred nickname if it differs from your first name

Mark all the ways that we can we use to contact you

*

check each method that we can use to contact you

Mobile phone

Personal email

Home phone

Work phone

Work email

Mobile Phone Number

Mobile phone carrier

FirstNet

ATT

Verizon

Sprint

US Cellular

T-Mobile

Other

Personal Email

Verify Email

Work email

Verify Email

Home Phone Number

Work Phone

Are you employed?

*

Check all that apply

Work for a business

Have my own business from home

Have my own business at another address

Between jobs

Retired

Homemaker

Student

Other

Describe Other

What did we miss on our list?

Name of Business/Employer/School

Enter the name of the place where you work or go to school

Physical Street Address where you work (not the mailing address)

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Occupation

what is or was your specific job function? List all that apply

Start Date

enter your start date as close as you can remember (doesn't have to be exact)

Physical Street Address where you currently live (not your mailing address)

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Date you began living there

*

(mm/dd/yyyy)

Is this also your mailing address?

Yes

No

Home mailing address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Have you lived anywhere else in the last 7 years?

*

Yes

No

(2) Prior Home Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(2) Date you began living there

(mm/dd/yyyy)

(2) Date you stopped living there

(mm/dd/yyyy)

(3) Have you lived anywhere else in the last 7 years?

Yes

No

(3) Prior Home Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(3) Date you began living there

(mm/dd/yyyy)

(3) Date you stopped living there

(mm/dd/yyyy)

(4) Have you lived anywhere else in the last 7 years?

Yes

No

(4) Prior Home Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(4) Date you began living there

(mm/dd/yyyy)

(4) Date you stopped living there

(mm/dd/yyyy)

(5) Have you lived anywhere else in the last 7 years?

Yes

No

(5) Prior Home Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(5) Date you began living there

(mm/dd/yyyy)

(5) Date you stopped living there

(mm/dd/yyyy)

Emergency contact name

*

First Name

Last Name

What types of phones can we use to contact your emergency contact?

*

check each type of phone that we can use to contact your emergency contact

Mobile

Home

Work

Emergency Contact Mobile Phone Number

Emergency Contact Home Phone Number

Emergency Contact Work Phone Number

Emergency Contact's relationship to you

*

Spouse / Partner

Significant Other

Parent / Guardian

Child

Friend

Other

Describe Other

If you marked "Other" for the emergency contact's relationship to you, please describe

Age and Health

Driver's License State

*

The state that issued your driver's license

Driver's License Number

*

enter your driver's license number

Driver's license expiration date

*

(mm/dd/yyyy)

Are you legally eligible to work in the United States?

*

Yes

No

Are you under age 18?

*

Yes

No

Enter your date of birth

*

(mm/dd/yyyy)

Do you have any health issues that the Brooklin Fire Department should know about?

*

Yes

No

would you like to discuss them in complete confidence with the Department Physician?

Yes

No

Are you willing to have a physical exam completed by physician? This exam would be confidential and paid for by the department.

*

Yes

No

Are you vaccinated against hepatitis B?

*

Yes

No

Can you provide the department with a record of your hepatitis B vaccination?

Yes

No

Are you willing to be vaccinated against hepatitis B?

The department of labor requires that all first responders be offered vaccination against hepatitis B because of the risks inherent in fire, rescue and medical emergencies. The Brooklin Fire Department will pay for your you to be vaccinated against hepatitis B. If you are not willing to be vaccinated against hepatitis B, you can sign a waiver.

Yes

No

HEPATITIS B VACCINE DECLINATION (MANDATORY)

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Hepatitis B vaccine waiver: Electronic Signature: Type your full name below as an electronic signature:

Entering your full name serves as an electronic signature for the Hepatitis B vaccine waiver

Hepatitis B vaccine waiver: Electronic Signature Date:

Enter today's date to validate your acceptance of the Hepatitis B vaccine waiver

Volunteer areas of interest

Are you able to respond to calls when working?

*

Yes

No

Major incidents only

Please mark the firefighting tasks that interest you

Select any jobs in each category that would interest you

Interior firefighting

Exterior firefighting

Engine pumping

Fire reports

Truck organization

Driving

Other

Please mark the medical response tasks that interest you

Select any jobs in each category that would interest you. NOTE that not all of these tasks require medical certification

EMT

EMS Training

EMS Support

Go-fer

Lift assist

Moral support

EMS reports

EMS supplies

Other

Mark the administrative tasks that interest you

Select any jobs in each category that would interest you

Public outreach

Parade duty

Bookkeeping

Fundraising

Inventory

Station organization

Other

List any other tasks that might interest you:

With proper training, would you be able to perform the essential functions of those jobs that you checked?

*

Yes

No

Can you be at the Brooklin Fire Station most Tuesday nights from 6:00 to 8:00?

*

Yes

No

Maybe once or twice a month

Have you ever been a member of a fire department, rescue squad or similar organization?

*

Yes

No

Name of previous fire department, rescue squad or similar organization

Town and State of previous fire department, rescue squad or similar organization

Name and rank of person at that agency that we can contact

Provide the name and rank of a leader at the previous organization that we can contact

Phone number of contact person at that agency

When did you start with that agency?

indicate the date that you started (approximate month and day are OK)

Are you still active with that agency?

are you an active member

Active member

Inactive member

No longer a member

When did you become inactive with that agency?

indicate the date that you became inactive (approximate month and day are OK)

Reason you are no longer active

Describe why you ceased to be active with that agency

Have you ever been a member of any additional fire department, rescue squad or similar organization?

*

Yes

No

Name of previous fire department, rescue squad or similar organization

Town and State of additional previous fire department, rescue squad or similar organization

Name and rank of person at that agency that we can contact

Provide the name and rank of a leader at the previous organization

Phone number of contact person

When did you start with that other agency?

indicate the date that you started (approximate month and day are OK)

Are you still active with that additional agency?

are you an active member

Active member

Inactive member

No longer a member

When did you become inactive with that additional agency?

indicate the date that you became inactive (approximate month and day are OK)

Reason you are no longer active with that additional agency

Describe why you ceased to be active with that agency

Please indicate all of your ACTIVE certifications:

check all that apply

Basic Firefighter (interior attack)

Firefighter 1

Firefighter 2

Wildland Firefighter

EMT First Responder

EMT-Basic

EMT-Intermediate

Paramedic

Other

Describe Other

Can you provide documentation of all certifications that you indicated?

Yes: All

Yes: Some

Maybe

No

Please describe why you may not be able to document all of your certifications

How did you hear about the Brooklin Fire Department?

*

Why do you wish to join the Brooklin Fire Department?

*

What can the Brooklin Fire Department gain from your membership?

*

What do you expect to gain from your membership?

*

Work History

List all employment and/or education for the past five (5) years, including full time, part time, temporary and seasonal employment.

Current Job

OK to contact current supervisor?

Yes

Only if absolutely necessary

No

Why would you rather we not contact your supervisor?

Name of supervisor

Supervisor's phone number

Supervisor's email address

Verify Email

Previous Job(s)

(1) Organization/Employer

Name of Organization / employer / business. Leave blank if none

(1) Job title / function

(1) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(1) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(1) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(1) Reason for leaving

(1) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(1) Name of supervisor

Name of current supervisor

(1) Supervisor's phone number

(1) Supervisor's email address

Verify Email

(1) Why would you rather we not contact this supervisor?

(2) Do you have another job to list?

Yes

No

(2) Organization/Employer

Name of Organization / employer / business. Leave blank if none

(2) Job title / function

(2) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(2) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(2) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(2) Reason for leaving

(2) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(2) Name of supervisor

(2) Supervisor's phone number

(2) Supervisor's email address

Verify Email

(2) Why would you rather we not contact this supervisor?

(3) Do you have another job to list?

Yes

No

(3) Organization/Employer

Name of Organization / employer / business

(3) Job title / function

(3) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(3) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(3) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(3) Reason for leaving

(3) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(3) Why would you rather we not contact this supervisor?

(3) Name of supervisor

(3) Supervisor's phone number

(3) Supervisor's email address

Verify Email

(4) Do you have another job to list?

Yes

No

(4) Organization/Employer

Name of Organization / employer / business

(4) Job title / function

(4) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(4) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(4) Reason for leaving

(4) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(4) Why would you rather we not contact this supervisor?

(4) Name of supervisor

(4) Supervisor's phone number

(4) Supervisor's email address

Verify Email

(5) Do you have another job to list?

Yes

No

(5) Organization/Employer

Name of Organization / employer / business

(5) Job title / function

(5) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(5) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(5) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(5) Reason for leaving

(5) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(5) Why would you rather we not contact this supervisor?

(5) Supervisor's phone number

(5) Supervisor's email address

Verify Email

(5) Name of supervisor

(6) Do you have another job to list?

Yes

No

(6) Organization/Employer

Name of Organization / employer / business

(6) Job title / function

(6) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(6) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(6) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(6) Reason for leaving

(6) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(6) Why would you rather we not contact this supervisor?

(6) Name of supervisor

(6) Supervisor's phone number

(6) Supervisor's email address

Verify Email

(7) Do you have another job to list?

Yes

No

(7) Organization/Employer

Name of Organization / employer / business

(7) Job title / function

(7) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(7) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(7) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(7) Reason for leaving

(7) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(7) Why would you rather we not contact this supervisor?

(7) Name of supervisor

(7) Supervisor's phone number

(7) Supervisor's email address

Verify Email

(8) Do you have another job to list?

Yes

No

(8) Organization/Employer

Name of Organization / employer / business

(8) Job title / function

(8) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(8) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(8) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(8) Reason for leaving

(8) Name of supervisor

(8) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(8) Why would you rather we not contact this supervisor?

(8) Supervisor's phone number

(8) Supervisor's email address

Verify Email

(9) Do you have another job to list?

Yes

No

(9) Organization/Employer

Name of Organization / employer / business

(9) Job title / function

(9) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(9) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(9) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(9) Reason for leaving

(9) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(9) Why would you rather we not contact this supervisor?

(9) Name of supervisor

(9) Supervisor's phone number

(9) Supervisor's email address

Verify Email

Describe all gaps in your work history in the last 5 years

Background Check authorization

The information contained in this application is correct to the best of my knowledge.

As a condition of membership in the Brooklin Volunteer Fire Company and Brooklin Fire Department, I hereby authorize those organizations and their designated agents and representatives to conduct a comprehensive review of my background causing a criminal report to be generated for volunteer purposes.

I understand that the scope of the criminal report may include, but is not limited to the following areas: verification of drivers license number; current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to the Brooklin Volunteer Fire Company and Brooklin Fire Department or their agents.

I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. I hereby release the Brooklin Volunteer Fire Company, Brooklin Fire Department, the Social Security Administration, and their agents, officials, representative, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.

Type your full name below as an electronic signature authorizing the Brooklin Fire Department to conduct a background check

*

Electronic Signature

Background check authorization date:

*

Enter today's date as part of your electronic signature authorizing the Brooklin Fire Department to conduct a background check

Use this field if there any part of your background that you would like to explain.

We are not here to judge. Help us understand the situation.