Brooklin Volunteer Fire Company

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Brooklin Fire Department Member Application

BFD Cross.jpg

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

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Prefix
First Name
Last Name
Suffix

Enter your middle or maiden name if you have one

Enter your preferred nickname if it differs from your first name
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check each method that we can use to contact you





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Check all that apply

What did we miss on our list?

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

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country

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

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

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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(mm/dd/yyyy)

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

(mm/dd/yyyy)

(mm/dd/yyyy)

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

(mm/dd/yyyy)

(mm/dd/yyyy)

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

(mm/dd/yyyy)

(mm/dd/yyyy)

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

(mm/dd/yyyy)

(mm/dd/yyyy)
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First Name
Last Name
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check each type of phone that we can use to contact your emergency contact



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If you marked "Other" for the emergency contact's relationship to you, please describe
Age and Health
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The state that issued your driver's license
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enter your driver's license number
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(mm/dd/yyyy)
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(mm/dd/yyyy)
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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.
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.

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

Enter today's date to validate your acceptance of the Hepatitis B vaccine waiver
Volunteer areas of interest
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Select any jobs in each category that would interest you
Select any jobs in each category that would interest you. NOTE that not all of these tasks require medical certification
Select any jobs in each category that would interest you
Select any jobs in each category that would interest you

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


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

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

Describe why you ceased to be active with that agency
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Provide the name and rank of a leader at the previous organization


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

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

Describe why you ceased to be active with that agency
check all that apply


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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




Previous Job(s)

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


Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

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

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







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


Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

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

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






Name of Organization / employer / business


Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

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

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






Name of Organization / employer / business


Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

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






Name of Organization / employer / business


Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

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

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






Name of Organization / employer / business


Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

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

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






Name of Organization / employer / business


Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

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

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






Name of Organization / employer / business


Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

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

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






Name of Organization / employer / business


Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

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

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






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. 

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

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