Membership Application

Instructions: Please type or print in ink all information requested on this form. Circle where necessary. If additional detail will be of value in answering these questions, use an additional sheet of paper. False or misleading statements may be cause for rejection or dismissal after appointment. Please also provide a brief description on why you would like to join the Clay Volunteer Fire Department.
APPLICATION FEE: $5.00 (to be paid upon submission of application)

Name:

Address:

Age:

Birth Date:

Sex:

Male
Female

City of Birth:

Height:

Weight:

Phone #:

Social Security #:

Email

Driver License or State / Gov. Issued ID #:

U.S. Citizen:

Yes
No

Present Employer:

Job Title:

Address:

Phone #:

Circle Desired Position:

Junior Firefighter (age 16-18)
Exterior Firefighter
Interior Firefighter
Honorary

List any experience:

Have you ever been convicted of any crime or offense of any degree other than traffic violations?

Yes
No

please give full details on an additional field

Is there anything about your health or physical condition which you know of that might be aggravated, become health hazard, or handicap your work under your duties as a Firefighter? The physical demand may be the ability to lift 80 lbs. and have the physical conditioning to work in a IDLH (Immediate Danger to Life and Health) environment for 30 minutes.

Yes
No

Please explain:

According to the by-laws of the Clay Volunteer Fire Department, each half of the year a member must attend at least 10% of the calls, 8 drills and 3 business meetings (approximately 80 hours each 6 months). Are you willing to volunteer such time? According to the by-laws of the Clay Volunteer Fire Department, each half of the year a member must attend at least 10% of the calls, 8 drills and 3 business meetings (approximately 80 hours each 6 months). Are you willing to volunteer such time?

Yes
No

If granted membership by the Clay Volunteer Fire Department, are you willing to submit to physical examination to verify you can physically perform the duties required of a member of the Clay Volunteer Fire Department?

Yes
No

I certify that the statements made by me in this application are true, complete and correct. By signing below, I hereby apply for membership with the Clay Volunteer Fire Department, and if granted said membership, I hereby confirm that I will abide by and obey all the rules, regulations, and By-Laws of the Clay Volunteer Fire Department. I also agree by affixing my signature below to obey all order and demands that may be directed to me by the LINE OFFICERS in command of the Clay Volunteer Fire Department after having taken the oath of said department.

Signature

Date

Printed Name

FOR INTERNAL USE ONLY

Membership Committee

Approval

APPROVED
DECLINED

Date

Emergency Contacts:

Name:

Relationship:

Address:

Phone:

Email:

Name:

Relationship:

Address:

Phone:

Email:

References:

List two references of individuals, not related, whom we may contact:

Name:

Relationship:

Address:

Phone:

Email:

Years Acquainted:

Name:

Relationship:

Address:

Phone:

Email:

Years Acquainted:

Junior Firefighter Only:

I

as Parent or Legal Guardian of

Child's Name

do hereby give permission for my child to participate in the Clay Volunteer Fire Department’s Junior Firefighter program.

Parent/Legal Guardian Signature

Date

arent/Legal Guardian Printed Name

FCRA Authorization to Obtain a Consumer Report (Background/Credit Check)

As part of the Clay Fire Department due diligence for new membership applications we conduct background checks through a third party. Can you please complete the attached authorization form and return it to me either via email or return it in the self-address stamped envelope enclosed.

I

authorize the complete release of these records or data pertaining to me that an individual, company, firm, corporation or public agency may have. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me to furnish Clay Fire Department, Inc or its designated agents with any and all information in their possession regarding me in connection with an application of employment. I am authorizing that a photocopy of this authorization be accepted with the same authority as the original.

I understand that, pursuant to the federal Fair Credit Reporting Act, if any adverse action is to be taken based upon the consumer report, a copy of the report and a summary of the consumer’s rights will be provided to me.

Signature

Date

Printed Name

Disclosure

We, Clay Volunteer Fire Department, Inc will obtain one or more consumer reports or investigative consumer reports (or both) about you for employment purposes. These purposes may include hiring, contract, assignment, promotion, re-assignment, and termination. The reports will include information about your character, general reputation, personal characteristics, and mode of living.

We will obtain these reports through a consumer reporting agency. Our consumer reporting agency is backgroundchecks.com (“BGC”). BGC’s address is P.O. Box 353, Chapin, SC 29036. BGC’s telephone number is (866) 265-6602. BGC’s website is www.backgroundchecks.com, where you can find information about whether BGC’s international privacy practices.

To prepare the reports, BGC may investigate your education, work history, professional licenses and credentials, references, address history, social security number validity, right to work, criminal record, lawsuits, driving record, credit history, and any other information with public or private information sources.

You may obtain a copy of any report that BGC provides and BGC’s files about you (in person, by mail, or by phone) by providing identification to BGC. If you do, BGC will provide you help to understand the files, including trained personnel and an explanation of any codes. Another person may accompany you by providing identification.

If BGC obtains any information by interview, you have the right to obtain a complete and accurate disclosure of the scope and nature of the investigation performed.

Please sign below to acknowledge your receipt of this disclosure.

Signature

Date

Printed Name