Emmitsburg,
Maryland
Vigilant Hose
Volunteer Fire Department
P.O Box 171
Emmitsburg, Maryland 21727
301-447-2728
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Position
Applying for: [ ] Active Firefighter [ ] Auxiliary Member [ ] Social Member
Last
Name: _______________________ First Name: ______________ Middle Initial: _____
Address:
_____________________________________
Home Phone: __________________________
_____________________________________________ Work Phone: __________________________
Email
Address: ______________________________________
Social
Security Number: ___________________________
Pager Number: _____________________
Driver’s
License Number: __________________________
Date Of Birth: _____________________
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In
Case of Emergency Please Notify: ____________________________________________________
Address:
___________________________________________________________________________
Home
Phone #: ____________________ Work
Phone #: ___________________ Other: __________
Doctor’s
Name: _____________________________
Phone Number: ___________________________
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High
School: _____________________________________
Address: __________________________
Highest
Grade Completed: ________ Date Graduated: _________ Date of GED:
________________
College
Attended: ________________________________ Degree Earned:
______________________
Address:
________________________________________ Credits Earned: ______________________
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Current
Employer: _______________________________
Position Held: ______________________
Address:
___________________________________________________________________________
Telephone
#: ________________________________ Dates Employed: From _________ to ________
Previous
Employer: __________________________ Position Held: ___________________________
Telephone
#: ________________________________ Dates Employed: From: _________ to ________
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References:
List three
character references whom you have known for at least 3 years and who are not
related to you. The references may not be past employers.
Address: ______________________________________________________________________
Address: ______________________________________________________________________
Address: ______________________________________________________________________
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Have you ever been a member of Vigilant Hose Co.
before? [ ] Yes [ ] No
If Yes, Date: _______
Have you ever served in another Fire Department?
[ ] Yes [ ] No If
yes, Date: ____________
Name
of Department: ________________________________________________________
Address:
___________________________________________________________________
Telephone
#: _______________________________ Date of Service: __________________
Name
of Current Chief: _______________________________________________________
Current
Chief’s Recommendation: _______________________________________________
List the types of
Fire/Rescue vehicles you have been authorized to drive:
a.
__________________
b. ___________________ c. _________________ d. ____________
State the highest Rank you held: _________________________________________________
List
any Fire/Rescue/EMS or related courses you have taken and where/how obtained. Attach
a copy of any certificates earned.
In
a brief statement, please explain why you want to become a member of the
Vigilant Hose Fire Department.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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Has your driver’s license ever been suspended/revoked? [ ]
Yes [
] No If yes, explain
circumstances, give dates of suspension and reinstatement:
__________________________________________________________________________________
__________________________________________________________________________________
Have you ever been convicted of a criminal offense in
adult court? [ ] Yes
[ ] No If yes, give details, including charge, location, and disposition
of case.
__________________________________________________________________________________
__________________________________________________________________________________
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I,
the undersigned, certify that I have read and fully understand this form in its
entirety and that the information herein is true and complete to the best of my
knowledge. I authorize the investigation of all statements made herein. I
understand that should any statement I have made prove to be false, misleading
or erroneous, it may result in the rejection of my application or in my
discharge from the Vigilant Hose Company. I also agree to uphold the rules,
regulations and Bylaws of the Vigilant Hose Company.
I
hereby authorize a police record check to be conducted as per Article 38A, of
the annotated Code Of Maryland. If elected to membership, I agree to provide
a certified copy of my driving record from the Motor Vehicle Administration at
my own expense.
Upon
resignation of my membership, I agree to return all items issued by the
Department including but not limited to protective gear and any other items
entrusted to me.
Applicant’s
Signature: _____________________________________ Date: ______________________