HVFD Online Application - Maryland Computer Service Inc.

Personal * Indicates Required Field

Submitted on: 11/12/2024 07:27

Membership Type: *

Name: *

Last, First, Middle Initial

Address: *

Street Address, City, State, Zip Code

How long have you lived at this address?: *

E-mail Address: *

Home Phone: *

Cell Phone: *

Sex: *

Date of Birth: *

Driver's License #: *

Driver's License State: *

Have you ever been convicted of a traffic violation, misdemeanor, or a felony: *

If Yes, indicate the date and nature of the charge, police agency, court, and disposition: *

If you were in the Armed Forces, when were you discharged? : *

Place Employment History

Place of employment:

Type of work performed:

Supervisors Name:

Supervisors Contact Information:

Medical History

Emergency Services work often requires a great deal of physical effort and stress in hazardous environments. Please list any medical restrictions that will / might affect your ability to fulfill the requirements of the service interest(s) you have chosen:

Previous Fire / EMS Experience

Have you ever filed an application to join the Department? : *

If yes, when? :

Have you ever been a member of any other fire, rescue or emergency medical department(s)? : *

If you have been a member of any other fire, rescue or emergency medical department(s) please list department name(s) and date(s) and contact information:

Have you ever been denied membership to a fire, rescue or emergency medical department? : *

If yes, please give details:

Have you ever been discharged for misconduct or unsatisfactory service or asked to resign from a fire, rescue or emergency medical services department? *

If you have been discharged, please give details:

List any firefighting and/or emergency medical certifications that are current.

Please provide copies of certifications:

Upload documents here. DOC, DOCX, PDF, XLS, XLSX, PPT, PPTX, TXT, JPG, JPEG, PNG

Education

High School Attended: *

Include Location (City/State)

Did you graduate or receive a GED: *

Date graduated, or received GED:

College, University, Graduate School, Technical / Professional School:

ILocation (City/State), Dates attended, Major, Degree, Certificate awarded

References (NOT Members of the Department)

Reference #1: *

Name, Address, Phone Number

Reference #2: *

Name, Address, Phone Number

Reference #3: *

Name, Address, Phone Number

Emergency Contact

Emergency Contact Information: *

Name, Relationship, Address, Phone Number, Additional Phone Number

Acknowledgement

How did you hear about us? : *

Select ALL that apply

County Recruitment Program

Friend

Member

Recruitment Flier

School Guidance Counselor

Social Media

State Recruitment Program

Please type your signature here: *

Please read the notice below before signing.

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY. If you do not understand any of them, or if you have any questions, please contact the Department at membership@hvfdems.org

By signing my digital signature above, I signify that I have applied for the membership to the Hughesville Volunteer Fire Department & Rescue Squad, Inc.; and that I have answered all questions truthfully and to the best of my knowledge; and that I fully understand that any intentional false statement may be considered cause for rejection of this application or grounds for dismissal from the Department. Furthermore, I hereby grant to the Hughesville Volunteer Fire Department & Rescue Squad, Inc. permission to contact my employer, references, and any other persons or agencies who may have knowledge of me, my skills and my experience as may be deemed necessary and to conduct a background investigation. I also understand that I will be required to undergo a physical examination, at the applicants' expense, as a condition of participating in any formal operational training programs. If you have any questions, please contact the Department at membership@hvfdems.org.