| Ct. fire danger |
http://www.ct.gov/dep/cwp/view.asp?a=2222&q=320740&depNav_GID=1631 |
| Contact Information |
Terryville Volunteer Fire Department Post Office Box 519 Terryville, Ct. 06786 Non-Emergency: 860-283-5021 Emergency: 911 Contact Us Driving Directions Map |
Application Print this page Application for Membership to theTERRYVILLE FIRE DEPARTMENT(Revision Date: October 27, 2009 TOWN OF PLYMOUTH P.O. BOX 519 ,21 HARWINTON AVE. TERRYVILLE CT. 06786-0519 860-283-5021 An Equal Opportunity Employer
Position applying for: Volunteer Firefighter Date of Application _____________
Hose Co #1____ Ladder Co #1____ Plymouth Co.____ Fall Mtn. Hose Co. #4_____
(Check one)
Please answer all questions and print legibly:
Name: ___________________________________________
Age _____ (Must be at least 18 years old)
Date of Birth ____________________ Social Security. _________________
Address__________________________ Town _________________________
Email Address ________________________
Telephone Number ( ) _________________________
May we contact you at work ? Yes ___ No___
Work Phone Number ____________________________
Cell Phone Number _____________________________
Have you ever worked under another name? __ Yes __ No
If yes, give name_____________________________________
Date you can begin _________________________________
Martial Status: Single ___ Married ___
Are you willing to go to Fire School on weeknights & weekends __ Yes __ No
Are you a previous applicant? __ Yes __ No
Are you a previous member of another Fire Dept?
(When & where)_________________________________________________________
Are you legally able to work in the United States __ Yes __ No
Are you a licensed driver with a car available? (Answer only if applicable to the position you are applying for? __ Yes __ No
Other than minor traffic violations have you ever been convicted of a crime, in the past 10 years which has not been annulled or expunged or sealed by a court?
__ Yes __ No.
If you answered Yes, Please provide details______________________________________
I understand that a conviction will not automatically disqualify me for membership with the Terryville Fire Department, but the Fire Dept. shall consider the nature of the conviction as it relates to the job duties in question and in light of the requirements of state and federal law.
Military service __ Yes __ No
If you answered yes, Please provide details:
Branch of service_________________________
Rank at discharge__________________
Dates of service_________________
List duties and any special training you completed_________________________________________________________________
Are you vaccinated against Hepatitis B? ____Yes ____ No
If yes, include a copy of your Hepatitis B vaccination card with this application. If you are not vaccinated against Hepatitis B, upon acceptance into the Terryville Fire Department, you will be offered the Hepatitis B vaccination at the expense of the Town of Plymouth.
Information for Physical Examination: Best day(s) of the week and time of day for a physical examination with Dr. Antonio Sacappaticci, 625 Clark Avenue, Bristol, CT 06010. ___________________________________________________________
General Information
Additional qualifications, special training/education, computer or office equipment skills and/or individual capabilities you have which prepare you for the position you have applied for: ____________________________________________________
________________________________________________________________________
Professional or licensure information (if applicable):________________________________
__________________________________________________________________________
List any professional certificates, registrations, or licenses (I.E., Commercial motor vehicle operators license) that you possess, if applicable to the position you are applying for:
Certification/license:__________________________________________________
Certification/License #, State and expiration date:______________________________________________________________
__________________________________________________________________
Have you ever been bonded? __ Yes __ No
If Yes, on what jobs?_________________________________________________
__________________________________________________________________
Education
Please complete all applicable items:
Please list any academic honors, scholarships, memberships in honor societies, etc., which you consider significant (Note: Please exclude any names, Title, Etc., Indicating Race, Sex, Color, National Origin or Religion)
__________________________________________________________________________
__________________________________________________________________________
Employment Record
List 3 references (no relatives or members of the Terryville Fire Department):
Please print.
Name ______________________________________ Address________________________________________
Name ______________________________________ Address________________________________________
Name ______________________________________ Address________________________________________
Acknowledgment
This application is not a contract of membership in anyway. All membership with the Terryville Fire Department is on an at-will basis, unless otherwise expressly provided. No official, agent or member of the Terryville Fire Department is authorized to change this membership at-will status. Therefore, either a member or the Terryville Fire Department can end the members relationship at any time and for any reason.
It is the policy of the Terryville Volunteer Fire Department to maintain a drug-free force to establish, promote and maintain a safe and healthy environment for members and citizens we serve. It shall be a violation of this policy for members to engage in the unlawful manufacture, distribution, possession or use of an illegal drug or controlled substance, including being under the influence or impaired while on duty.
I understand that (1) the Terryville Volunteer Fire Department has a drug policy that provides for premembership testing and (2) consent to and compliance with such policy is a condition of my membership.
By your signature below, you acknowledge and aver that there are no misrepresentations, omissions, or falsifications of any kind in the foregoing statements and answers, and that the responses given are true, complete and accurate to the best of your knowledge and are made in good faith. Any misrepresentation, omission or falsification in the foregoing statements and answers, or at any time during the application process, is grounds for disqualification from membership, and, if you are accepted , without limiting the at-will status of your membership, grounds for immediate discharge.
By your signature below, you also authorize, and discharge from all liability, the Terryville Fire Department & the Town of Plymouth and all educators, employers and references listed in this application, regarding the furnishing of the Terryville Fire Department with information regarding your education, employment history, and any other matter related to your application for membership. The Terryville Fire Department will, upon request, supply a copy of this acknowledgement to any educator, employer or reference the Terryville Fire Department contacts in regard to this application. The Terryville Fire Department reserves the right to conduct all lawful background checks in connection with your application for membership, including but not limited to a credit report check. Upon your written request, the Terryville Fire Department will supply you one copy of any such report(s) it receives.
If accepted, you agree to comply with all rules, regulations and policies governing membership with the Terryville Fire Department, as currently in force and as the same may from time to time be amended, deleted, revised or modified.
Signature_____________________________ Date ______________
Printed name of applicant ______________________________________
Authorized Witness______________________________ Date ___________
Printed name of witness_________________________________
TERRYVILLE FIRE DEPARTMENT
TOWN OF PLYMOUTH P.O. BOX 519 21 HARWINTON AVE. TERRYVILLE CT. 06786-0519
RELEASE AUTHORIZATION
To: All Courts, Probation Department, Law Enforcement Agencies, Selective Service Boards, Physicians, Hospitals, Employers, Education and other Institutions, and Agencies without exception.
I,_________________________________ am making application or am being considered for Terryville Fire Department membership. As a result, an investigation is being conducted to determine my eligibility. Therefore, you are authorized to release to the Terryville Fire Department or its representative any and all information, documentary or otherwise pertaining to me, that they may request.
I hereby release, discharge and exonerate the Terryville Fire Department & the Town of Plymouth, its agents and representatives, and any person so furnishing information from any and all liability of every nature and kind arising out of the furnishing, inspection or collection of such documents, records, and other information or the investigation made by the Terryville Fire Department & the Town of Plymouth.
A Photostat copy of this authorization will be considered as effective and valid as the original.
Signature________________________________________
Date of Birth_______________________
Address_________________________________________
Sworn to me this _______________ day of ________________ year
Notary Public:______________________________________
My Commission expires______________________________
|
| Upcoming Events |
Every 2nd Thu. 7:30pm comm. meeting |
Every 4th Mon. 7:00pm co. monthly meetings |
| Apparatus Gallery |
 |
| Visitor Poll |
Did you know that the Terryville Fire Dept. is 100% volunteer? |
| Links |
Ct. Fire marshals |
Shipmans fire equipment |
Wolcott State Regional Fire School |
 Login |
Copyright © 2006-2010. YourFirstDue Inc.. All Rights Reserved. Designated trademarks and brands are the property of their respective owners. Content on this web site is supplied by Terryville Volunteer Fire Department. YourFirstDue Inc. cannot be held responsible or liable for any content, text, pictures, or any other media found on this web site. Maintained by the members and staff of Terryville Volunteer Fire Department. |
This site has been viewed 64,847 times. |