Membership Application - Murray Joint Fire District

Department Membership Appling For Required

Fancher Hulberton Murray Fire Company Holley Volunteer Fire Company

Name

Address

Phone Number Required

How long have you lived at your present address Required

Years, Months

If less than 2 years, please list your prior addresses for the last two years

Do you intend to reside in the Murray Joint Fire District for the next few years Required

No Yes

If you do not plan to reside in the Murray Joint Fire District for the next few years, please explain why

Are you at least sixteen years of age Required

No Yes

Do you possess a valid N.Y.S. driver’s license Required

No Yes

Employment Information #1

Name, Address, Position, Dates of Employment

Employment Information #2

Name, Address, Position, Dates of Employment

Do you have access to a vehicle to permit you to respond to the station Required

No Yes

Please check all the positions for which you intend to become qualified and perform Required

Interior Firefighter Scene Support Fire Police Emergency Medical Technician or Emergency Medical Responder

List any relevant certifications, courses, trainings (please provide expiration dates, if any)

File Upload - Certifications, Courses, Trainings

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What is your highest grade/level of education completed Required

Have you previously belonged to another fire department or ambulance service Required

No Yes

If you have belonged to another fire dpartment previously provide name, address, and years of service

Are you a citizen of the United States Required

No Yes

If not, do you intend to become a citizen of the United States

No Yes

If no, have you the legal right to remain permanently in the United States

No Yes

Do you intend to remain permanently in the United States

No Yes

Have you ever been convicted or plead to a criminal offense Required

No Yes

Provide offense convicted of

Date of conviction

How long ago was the conviction

Has a certificate of relief from disabilities been obtained

No Yes

Have you ever been convicted of Arson or attempted arson in any degree Required

No Yes

Have you ever been convicted of an offense requiring registration as a sex offender Required

No Yes

Do you have any pending arrests Required

No Yes

Have you reviewed the requirements for the position which you are interested Required

No Yes

Can you perform the functions of at least one of the positions in which you are interested, with or without reasonable accommodation* Required

(Please see the attached list of physical requirements) * The fire district and or companies reserves the right to determine what is reasonable.

No Yes

Reference #1 Required

Name, Address, Phone Number, Relationship

Reference #2 Required

Name, Address, Phone Number, Relationship

Reference #3 Required

Name, Address, Phone Number, Relationship

I hereby consent to a criminal background check Required

Yes

Electronic Signature of Applicant Required

By providing my electronic signature above, I hereby consent to a criminal background check and to the review of information that may be publicly available on social media platforms. I understand that this information will be used solely to assess my eligibility for membership based on legal grounds. I acknowledge that findings from this review may lead to the denial of membership solely for legal reasons.