Watkins Glen Fire Department
201 North Perry Street
Watkins Glen, New York, 14891-0429
Phone: 607-535-7700 Fax: 607-535-9315
Email- watkinsglenfiredepartment@verizon.net
Application for Membership
The Watkins Glen Fire Department actively recruits from the community for
firefighters and emergency medical personnel. Thank you for considering volunteering in
the emergency services. Without your help a paid service would be required which our
small communities would not be able to afford.
Requirements for Membership:
A person must meet the residency requirements of the Watkins Glen Fire
Department which are live, work, or reside in the vicinity of the fire district. A person
meeting these requirements will submit an application; the application will be processed
and a background check will be conducted. At the first regular monthly meeting
following the background check the application will be voted on and the applicant will be
notified of the results. Persons transferring from another fire department will be voted on
at the first regular monthly meeting following the submission of their application and
successful background check.
A person must at least 17 years of age to join the fire department. Regular monthly
meetings are held on the first Thursday of every month at 7:30 p.m. at the fire station.
Each member shall be present at a minimum of 4 regular monthly meetings a year.
Training is generally conducted 3 to 4 times a month on Mondays, Saturdays, and
some Wednesdays. Additional State Fire and State EMS trainings will be offered as well
as be available to you. Each member is required to attend a minimum of 18 hours of
training a year.
A new member within 1 year no longer than 2 is required to enroll in the New York State
Office of Fire Prevention and Control. By enrolling the new member will meet their
minimum training requirements for fire departments set forth by the State of New York.
Failure to enroll will result in termination from the fire department.
Your application will be reviewed by the department foreman who will submit the
application at the regular monthly meeting. The foreman will contact your references to
verify your information. The foreman will conduct an interview with you. During the
regular monthly meeting at which your application is being voted on you may wait
outside the meeting room for the results. If favorable you will be invited inside the
meeting room to join the department. If you choose not wait outside the meeting room the
Foreman will contact you by telephone and advise you of the results.
1
Date of Application:
Last Name:
First Name:
MI
Address:
Apt/Suite #:
City, Town, Village:
Telephone #:(
State:
)
Home(
Zip:
)
(work)
Email:
Sex:
M
F
DOB:
/
/
S.S. #:
-
-
How long have you resided at the above address? Years
Months
How long have you resided in New York State? Years
Months
Are you 17 years of age or older?
Yes
No
If no, state your age
Is additional information necessary to enable a check on your eligibility for membership
(a change in your name or an assumed nickname.? Yes
No
If yes, explain:
Are you currently employed? Yes
No
Name of company:
Address
May we contact your employer as a reference? Yes
Do you have a valid New York State driver’s license? Yes
License #
Expiration:
Telephone # (
)
No
No
Previous emergency service experience: (please include only fire, ems, rescue, and
police.)
Name of agency or agencies:
Contact person or persons:
Telephone #s:
2
Have you ever been a member of the United States Armed Forces? Yes No
If yes, did you receive a dishonorable discharge? Yes
No
If yes give full details on the additional information page. Please be sure to include
service branch and service dates.
Have you ever been convicted or pled guilty to a felony, misdemeanor, insurance fraud,
arson, or a reduction of one of these offenses? Yes
No.
If yes, give full detail on the additional information page.
OSHA and NFPA regulations require that you pass a physical examination before
becoming an interior structural firefighter. The Village of Watkins Glen and the Watkins
Glen Fire Department require you to pass a physical examination before becoming a level
1, 2, or 3 firefighter. The departments designated physician will provide you with a free
examination. Will you be willing to undergo a medical examination? Yes
No
References:
Please list three references that you have known, other than members of this
organization, for at least three years.
Name:
Address:
Telephone:(
)
Name:
Address:
Telephone: (
)
Name:
Address:
Telephone: (
)
Please list the names of any acquaintances that are members of this organization:
Applicants Signature:
3
Emergency Contact Information:
Name:
Address:
City:
ST
Zip
Relationship
Phone (
Additional Information
4
)
Applicants Authorization for Release of Information
In order to confirm the information I have supplied on my application for membership
with the Watkins Glen Fire Department, I authorize all licensing agencies, educational
institutions, law enforcement, present and former employers, and the military to disclose
their relevant records about me to the Watkins Glen Fire Department weather the
information be of public, private, or confidential nature; and I release them from any
liability and responsibility from doing so. This authorization, in original copy form, shall
be valid for this and any future information, reports, or updates that may be requested. I
understand that this form will accompany a request for official documents and
conformations of my credentials.
Applicants Name: Please Print
Signature:
Date:
Signature:
Date:
Witnessed By:
Name and Title:
Please Print
Drivers License Report Notification:
I understand that my position with the Watkins Glen Fire Department requires my
driver’s license to meet the standards set by their insurance company and agency driving
policy. If my driver’s license now or in the future fails to meet these requirements, I
understand I will be subject to the actions outlined in the driving policy. I also understand
that this release in no way represents an employment contract with the Watkins Glen Fire
Department.
Applicant/Employee Signature:
Date:
Witness:
Date:
Drivers license information:
Name as it appears on license:
Date of Birth:
Driver’s license number:
Issuing State:
Expires:
5
In accordance with the NYS Department of Health the Watkins Glen Fire Department is
required, under 29CFR 1910.1030 CSMA BBP Law, to inform you that during your
normal scope of duties here you may be subjected to the Tuberculosis, Hepatitis, and
other airborne or blood borne diseases. Within 10 days of your application being
approved you must be offered the Hepatitis B Vaccine and you will be given the option to
have a Tuberculosis test. Tuberculosis tests will be offered yearly. If you choose not to
receive the Hepatitis B Vaccine by signing below you are acknowledging that is has been
offered to you by the Watkins Glen Fire Department and that you understand the risks
involved with not receiving the vaccine. By signing below you are also acknowledging
that you choose to receive the vaccine offered to you. Please sign on the correct line.
I wish to receive the Hepatitis B Vaccine
Printed Name:
Sign Name:
Date:
I decline to have the Hepatitis B Vaccine.
Printed Name:
Signed Name:
Date:
`
6