Dear Prospective Member;

Thank you for your interest in becoming a member of the Kent Island Volunteer Fire Department, Inc. The complete membership application package is attached to this application. It is very important you complete all requested information which will be verified and references checked. Failure to provide complete and accurate information will result in your application being rejected. Please follow the instructions below to ensure there is no delay in processing your applications.

Your responsibility:

1. Complete all forms in this package.
2. Detach and retain the “substance abuse policy”, return the signature page of this policy with your application.
3. Return the application package to the membership committee or any Fire-EMS line or Administrative Officer.
4. Be sure to submit all requested documentation (i.e.: training, report card, etc.) 
5. You will be contacted to setup an interview.
6. Applicant’s age 18, or UNDER; including applicants for Cadet will be interviewed with parent or guardian present at interview.

Our responsibility:

1. Your application will be read to the membership at the first meeting after it is received.
2. The Membership Committee will contact you to schedule an interview. During the interview process, you receive information on how and where to schedule your physical, background and drug test. Failure to pass this test my result in the termination of your membership. If you have a current physical (within the past year) and recent drug test or background check (within the past 30 days), please bring a copy to the interview.
3. After the physical and drug test have been completed, or proper documentation has been submitted, your application will be brought before the membership for their vote during the membership meeting.

Should you have any questions during this application process, please contact a member of the membership committee.

See attached list

Substance Abuse Policy
Hepatitis “B” Vaccination Consent/Declination Form
Medical Information Sheet

Indicates Required Field

Submitted on:		07/27/2024 0146
Position applying for:		Select Below Active Member Associate Cadet EMS Day Staff
Name: Last, First, Middle
Address: House Number/Post Office Box No., City, State, Zip Code
Date of Birth:
Social Security Number:
Home Phone #:
Work Phone #::
Cell Phone #:
Email Address:
Marital Status:		Select Below Divorced Married Separated Single Widowed
Divorced Married Separated Single Widowed:		Select Below 0 1 2 3 4 5 6 7 8 9 10+
Do you have a valid driver’s license?:		Select Below Yes No
License State of Issue:		Select Below Alabama - AL Alaska - AK American Samoa - AS Arizona - AZ Arkansas - AR California - CA Colorado - CO Connecticut - CT Delaware - DE District of Columbia - DC Federated States of Micronesia - FM Florida - FL Georgia - GA Guam - GU Hawaii - HI Idaho - ID Illinois - IL Indiana - IN Iowa - IA Kansas - KS Kentucky - KY Louisiana - LA Maine - ME Marshall Islands - MH Maryland - MD Massachusetts - MA Michigan - MI Minnesota - MN Mississippi - MS Missouri - MO Montana - MT Nebraska - NE Nevada - NV New Hampshire - NH New Jersey - NJ New Mexico - NM New York - NY North Carolina - NC North Dakota - ND Northern Mariana Islands - MP Ohio - OH Oklahoma - OK Oregon - OR Palau - PW Pennsylvania - PA Puerto Rico - PR Rhode Island - RI South Carolina - SC South Dakota - SD Tennessee - TN Texas - TX Utah - UT Vermont - VT Virgin Islands - VI Virginia - VA Washington - WA West Virginia - WV Wisconsin - WI Wyoming - WY
License #::
License Class:
Expiration Date:
Current number of points:
Endorsements:
Have you ever been convicted of any motor vehicle violations other than parking?:		Select Below Yes No
If you have ever been convicted of any motor vehicle violations other than parking, please explain:
Have you ever been convicted of any other violations of the law?:		Select Below Yes No
If you have ever been convicted of any other violations of the law, please explain:
List two personal references: (NO Family Members)
Reference #1: Name, Address, Telephone #, Years Known
Reference #2: Name, Address, Telephone #, Years Known
Employment History
What is your occupation:
Name of employer:
Address of employer:
How long have you worked there:
Work hours:
Personal Information
Are you in good physical condition:		Select Below Yes No
Do you have any physical limitations:		Select Below Yes No
If you have any physical limitations, please explain:
Are you now a member of any volunteer fire or ambulance company:		Select Below Yes N
If yes, which company:
Have you ever been a member of any volunteer fire or ambulance company:		Select Below Yes No
If yes, list the company name, dates of service and reason for leaving:
List any current fire or EMS certifications: Include ID #’s and expiration dates if applicable
Applicants currently enrolled in high school must attach a copy of their most current report card:		Add files...
Attach a copy of all Fire and EMS training cards, certificates, etc. to this application:		Add files...
Acknowledgement
Electronic Signature of applicant:
Parent / Guardian Electronic Signature ( if applicant is under 18 years of age):
I hereby acknowledge all facts presented in this application are true to the best of my knowledge and authorize Kent Island Vol. Fire Dept., Inc. Officers and Membership Committee to conduct a full investigation of my background and the information listed. I understand any false information presented by me is automatic grounds for dismissal from the membership process and that my application to the Kent Island Vol. Fire Dept. may be denied for any reason deemed appropriate by the officers and members of said organization. I will not hold any member of the Kent Island Vol. Fire Dept., Inc. responsible for any information revealed, discussed, or presented during the investigation. I understand that I must successfully pass a physical examination and drug test provided at no cost to me by the Kent Island Vol. Fire Dept., Inc. Failure to pass the physical and/or drug test may result in termination of my membership. I acknowledge receipt of a copy of the current company bylaws that I promise to abide by. I further agree to comply with requirements set forth in the bylaws for probationary members. My failure to comply with requirements of the bylaws will result in termination of my membership.