Greenland Volunteer Fire Department Application for Membership

www.GreenlandFire.org        

Name: ___________________________________              DOB: ______________________

Address: __________________________________                Soc. Sec. #: _________________

_________________________________________              Home Phone: ________________

Volunteer Interest:
To volunteer, you must be at least 18 years old and a New Hampshire resident.

 

Firefighter Only _____  EMT Only_____                   Firefighter/EMT _____

Dispatcher______                  Support Group _____            

Employers:
Please list your employers for the past five years.

Company Name               Address                                                           Phone Number

Experience and Education:

          Name and Address of School                                   Year Graduated

High School: ________________________________________________________________

College: ____________________________________________________________________

Please attach copies of all fire and/or EMT certifications, cards and licenses.

Fire and/or EMT Experience:

___________________________________________________________________________

__________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

________________________________________________________________________

Emergency Contact:

Name: _______________________________            Relationship:___________________

Address: ________________________________________________________________

Home Phone: _________________________          Work Phone: __________________

I understand that as an active member of the Greenland Volunteer Fire Department I will be required to attend emergencies, drills, training, meetings and work details as well as follow the by-laws of the department.

By signing and submitting this application I attest that all statements above are true and authorize the Greenland Volunteer Fire Chief and/or their agents to verify.  I give authorization for a motor vehicle and criminal background check to be performed, and any other background review deemed necessary. 

Applicants signature: ________________________________ Date: _________________

To submit an application please include:

• Signed application for membership
• Completed physical report
• Photocopy of your driver’s license
• If applicable, copies of fire and/or EMT certifications, cards and licenses

Mail your application, or drop it off at the department on the second Tuesday of each month during our meeting at 7:00 pm.
                       

Greenland Volunteer Fire Department – Chief

575 Portsmouth Avenue

Greenland NH 03840                                   

Questions?  Call the Fire Station at 436-1188 or e-mail GVFD21@yahoo.com

Physical Report

Name of Applicant: ___________________________________

Social Security #: ________________________________            Date of Birth: ____________

The following medical information must be provided and signed by a medical doctor.

Height: ________________________            Weight: ____________

Vision:              Left eye: ___________            Right eye: __________

Both eyes: __________            Corrected: __________

Blood Pressure: _____/______            Pulse: ________            Hearing: ________________

General Physical Condition:

Heart: _________________________________

Lungs: ________________________________

Hernia: ________________________________

Physical Defects: ____________________________________________________________________

Relevant History: _______________________________________________________

I have examined _____________________________ and find him/her physically fit for performing the duties of a firefighter/EMT Responder.

Signed: _________________________________

Name: __________________________________

Address: _________________________________________________________

Phone:   ___________________________________

                             Questions, comments, or suggestions?

                            Greenland Volunteer Fire Department Copyright 2008