Online Membership Application

Member Type*
Regular MemberAssociate Member

Home Agency (if applying as an Associate Member)

First Name*

Middle Initial*

Last Name*

E-mail Address*

Address *

City/Town/Village*

State*

Zip/Area Code*

Home Phone

Work Phone

Mobile Phone

How long have you resided at the above address?*

How long have you resided in New York State?*

Are you 18 years of age or older?*
YesNo
If NO, state your age:

Is additional information about a change in your name or your use of an assumed name or nickname necessary to enable a check on your eligibility for membership?*
YesNo
If YES, explain:

Are you currently employed?*
YesNo

If YES, please provide employer information below. May we contact your employer as a reference?
YesNo
Name of Company

Company Address

Company Phone

Do you have a New York State driver's license?*
YesNo
Driver's License Number

Please indicate your availability to participate in normally scheduled rescue squad activities (meetings, drills, and emergency calls).

Weekdays:MorningsEveningsNights
Weekends:MorningsEveningsNights

Previous emergency services experience: (include only fire, rescue, police, and emergency medical service agencies)

Name of Agency

Contact Person

Address

Telephone

Have you ever been a member of the United States Armed Forces?*
YesNo
If YES, did you receive an honorable discharge?
YesNoNever served
If NO to the previous question, indicate discharge type:

If you answered YES to being a member of the Armed Forces, please provide details in the space provided below (include service branch and service dates).

Have you ever been convicted or plead guilty to a felony, misdemeanor, insurance fraud, arson, or a reduction of one of these offenses?*
YesNo

If YES, please give details in the space below.

Please list three personal references, other than members of this organization, who have known you for at least three years.

Reference 1 Name*

Reference 1 Telephone *

Reference 1 Address*




Reference 2 Name*

Reference 2 Telephone*

Reference 2 Address*




Reference 3 Name*

Reference 3 Telephone*

Reference 3 Address *

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

Our By-Laws require that you pass a physical examination and drug test before becoming a member. The department's designated physician will provide you with a free medical examination. Will you be willing to undergo a medical examination and drug test?*
YesNo
Will you be willing to undergo random drug screenings once you become a member?*
YesNo