Membership

Membership Application Package Hyattsville Volunteer Fire Department This document has been created to familiarize prospective members with the opportunities and benefits offered by joining the membership of the Hyattsville Volunteer Fire Department. This guide will briefly explain the minimum qualifications needed to become a member and serves to explain the interview and admission process. We welcome your feedback.		contents >from the recruitment committee >application for membership >personal file data form ORIGINAL PUBLICATION: August 11, 2011

Hyattsville Volunteer Fire Department

Fire – Rescue – Emergency Medical Services

6200 BELCREST ROAD – HYATTSVILLE, MD 20782

www.hvfd.com – 301/927-5770 – [e-mail]
Dear Applicant,

Thank you for your interest in joining the Hyattsville Volunteer Fire Department. We welcome you to the membership application process.

The details of this process are outlined in the Prospective Member Guide. If you have not yet received this guide, please contact us to arrange getting one to you. Please take the time to review the guide closely before you fill out the application.

We will be available if you have any questions throughout the process – and also when you become a member of our organization. Once you have completed the application, please email [e-mail] to arrange a brief appointment where we will check the application for completeness and answer any questions you may have, as well as schedule an interview with you. At that time, we can also schedule a ride along with us.

We look forward to meeting you and hope to make you feel at home at the Hyattsville Volunteer Fire Department.

Thank you in advance for your consideration. Please do not hesitate to contact us should you require further information.

Sincerely,

HYATTSVILLE VOLUNTEER FIRE DEPARTMENT

Recruitment & Retention Committee

[e-mail]

Hyattsville Volunteer Fire Department

Fire – Rescue – Emergency Medical Services

6200 BELCREST ROAD – HYATTSVILLE, MD 20782

www.hvfd.com – 301/927-5770 – [e-mail]

> application for membership

Today’s Date:

/ /

1.

What form of membership are you seeking?

FIRE/EMS

EMS ONLY

ADMIN/ASSOCIATE

2.

CONTACT INFORMATION:

Last Name

First Name

MI

Street Address

Apartment #

City/Town

State

Zip

Home Phone

Cell Phone

E-Mail Address

3.

Is additional information about a change in your name, or use of an assumed name or nickname, necessary to enable a check on your eligibility for membership? If you answered YES, please provide details on the “Additional Information Page”

Yes

No

4.

How long have you resided at the above address?

Years

Months

5.

Are you 18 years of age or older?

Yes

No

6.

Do you have a valid Driver’s License? What State? _______________ What Is Your License Class? _____________________________

Yes

No

7.

Have you ever been a member of the US Armed Forces? NOTE: If you answered YES, please provide details on the “Additional Information Page.” List branches and dates.

Yes

No

If you answered YES, did you receive a dis-honorable discharge? NOTE: Dishonorable discharge is not an absolute bar to membership. This and other factors will affect a final decision. If you answered YES, please provide details on the “Additional Information Page”

Yes

No

8.

Have you ever been convicted, or found guilty of a felony, misdemeanor, insurance fraud, arson, and alcohol related vehicle and traffic offenses or pled guilty to a reduction of one of these offenses, and the records of same were not expunged. NOTE: 1. If you answered YES, please provide details on the “Additional Information Page.” 2. A conviction of an alcohol related vehicle and traffic offense will not automatically disqualify an applicant from membership with the Hyattsville Volunteer Fire Department. It may, however bear upon the qualification of an applicant to be certified as a driver of the Fire Department’s apparatus.

Yes

No

9.

OSHA regulations require that you pass a physical examination after becoming a member of this department. The Prince George’s County Fire Commission’s designated medical provider will provide you with a free medical examination. Will you be willing to undergo a free medical examination?

Yes

No

10.

When are you generally available to participate in Fire Company Activities? (Meetings, drills, responses, fundraising, work details etc.) [Circle all that apply]

Weekdays

Days

Evenings

Nights

Weekends

Days

Evenings

Nights

11.

Do you have any previous emergency services experience? If so, indicate below. NOTE: Please indicate only Fire, Rescue, EMS, Police or HazMat or relevant experience.

Agency Name

City/State

Supervisor’s Name & Position/Title

Supervisor’s Phone Number

Reason for leaving

Agency Name

City/State

Supervisor’s Name & Position/Title

Supervisor’s Phone Number

Reason for leaving

Agency Name

City/State

Supervisor’s Name & Position/Title

Supervisor’s Phone Number

Reason for leaving

ADDITIONAL INFORMATION
In regards to Item#:
In regards to Item#:
In regards to Item#:
In regards to Item#:
In regards to Item#:

+++ USE ADDITIONAL PAPER AS NECESSARY +++

ACKNOWLEDGEMENT
INITIAL HERE	I acknowledge that all of the statements made herein are true to the best of my knowledge. I authorize investigation of all statements made in this application. I acknowledge that any false statements or material omissions could lead to rejection as a candidate or termination as a member if the falsity or omission is learned subsequent to my acceptance as a member.
INITIAL HERE	I acknowledge that I desire to promote the Hyattsville Volunteer Fire Department’s objectives to protect life and property, prevent and extinguish fires, and mutually further the moral and intellectual improvement of its members as set forth in the Hyattsville VFD’s by-laws, rules & regulations.
Your Signature		Date

FREEDOM OF INFORMATION
Within the Freedom of Information Law (FOIL), all information contained or obtained herein will remain confidential and will be used only for internal membership processing. In witness whereof, this application has been subscribed on the date indicated below by the undersigned applicant who affirms that the statements made herein are true, under penalties of perjury.
Your Signature	Date
Print Witness Name	Witness Signature

EQUAL OPPORTUNITY NOTICE

The Hyattsville Volunteer Fire Department does not discriminate on the basis of age, gender, creed, religion, or marital status. If an applicant is approved for membership, such approval is conditional upon final receipt of references and background information consistent with the standards of the Hyattsville Volunteer Fire Department. A conditionally approved member may be dismissed at any time and for any reason within twelve (12) months of his /her acceptance as a conditional member.

REFERENCES
12.	EMPLOYMENT REFERENCES:
	Are you currently employed?
				Yes	No
	May we contact your employer as a reference? NOTE: If you answered YES, please complete the information below
				Yes	No
	Company Name		Number of Years Worked There
	Your Position/Title
	Supervisor’s Name		Supervisor’s Phone Number
13.	PERSONAL REFERENCES: Please list three personal references, other than family, clergy or members of this organization, who have known you for at least three (3) years
A.
	Last Name	First Name
	Relationship to Applicant			Phone#
B.
	Last Name	First Name
	Relationship to Applicant			Phone#
C.
	Last Name	First Name
	Address			Phone#
14.	FIRE DEPARTMENT REFERENCES: Please list any acquaintances who are members of our organization.
A.
	Last Name	First Name
B.
	Last Name	First Name
C.
	Last Name	First Name

CONFIRMATION OF MINIMUM REQUIREMENTS FOR FIRE/EMS AND EMS ONLY MEMBERS
YES / NO	I will be able to commit to the minimum of two nights a month for duty shift from 6 p.m. to 10 p.m. weeknights and
YES / NO	I will be able to commit to the minimum one weekend 24-hour shift per month, from 6 p.m. to 6 a.m.
YES / NO	I will complete the minimum training requirements outlined in the HVFD Prospective Member Guide within the time periods outlined.
YES / NO	I have read the HVFD Prospective Member’s Guide and understand and agree to meet the requirements of members outlined within.

EMERGENCY CONTACT
Name	Relationship
Primary Phone	Secondary Phone

www.hvfd.com – THE HYATTSVILLE VOLUNTEER FIRE DEPARTMENT – [e-mail]

6200 BELCREST ROAD – HYATTSVILLE, MD 20782 – 301.927.5770