Fire Membership Application | Village of Oxford Fire

Village of Oxford Fire Department

PO Box 570
Oxford, NY 13830

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for membership without regard to race, color, religion, sex, national origin, age, marital status, or the presence of a non-job related medical condition or handicap.

TO BE COMPLETED BY THE APPLICANT

1. Last Name*:

M.I.:

First Name*:

2. Address*:

3. Mailing Address (if different) :

3. City, Town, Village *:

State*:

Zip*:

4. Home Telephone Number:

Work Phone:

Cell Phone/Pager*:

5. E-mail Address*:

6. Driver Identification Number*:

Class

7. How long have you resided at the above address?

Years:*

Months:*

If less than 2 years, provide previous address.

8. How long have you resided in New York State?

Years:*

Months:*

9. Are you 18 years of age or older?* Yes No

Date of Birth:*

10. Are you a citizen of the United States?* Yes No

11. If you are not a citizen of the United States, have you the legal right to remain permanently in the United States? Yes No

12. Have you been known by any other name (e.g. marriage)? Yes No

If so, list name(s) and reason (necessary to enable a check on your application).

13. Are you currently employed? Yes No

14. Please indicate your availability to participate in normally required fire department activities (meetings, drills, and emergency calls).

Weekdays:

Day, Evening, Night,

Weekends:

Day, Evening, Night,

15. Previous emergency services experience: (Include only fire, rescue, police, and emergency medical agencies).

Name of Agency

Address

Duties

16. Have you ever been a member of the United States Armed Forces? Yes No

If the answer is “Yes”, did you receive a dishonorable discharge? Yes No

Dishonorable discharge is not an absolute bar to membership. This and other factors will effect a final membership decision. If the above answer is “Yes”, provide details (include service branch and service dates).

18. Have you ever been convicted of criminal mischief, insurance fraud, arson or a reduction of one of these offenses? Yes No

If “Yes”, provide details

19. Please list people in your circle of friends who have known you for at least 3 years; people you socialize with.

Name #1

Phone #1

Address #1

Name #2

Phone #2

Address #2

Name #3

Phone #3

Address #3

20. Please list the names of any acquaintances that are members of this organization:

Applicant’s Signature*:

Date*:

Fire Department Membership Application

Village of Oxford Fire Department

PO Box 570
Oxford, NY 13830

TO BE COMPLETED BY THE APPLICANT

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Village of Oxford Fire Department

PO Box 570 Oxford, NY 13830

TO BE COMPLETED BY THE APPLICANT

Complete CAPTCHA requirements or your form data may be lost.

PO Box 570
Oxford, NY 13830