Fillable CITY OF CANANDAIGUA FIRE DEPARTMENT APPLICATION FOR VOLUNTEER (City of Canandaigua)

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CITY OF CANANDAIGUA FIRE DEPARTMENT APPLICATION FOR VOLUNTEER (City of Canandaigua)

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BROWSE CITY OF CANANDAIGUA (NY) FORMS

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CITY OF CANANDAIGUA
FIRE DEPARTMENT
Fire Chief Frank Magnera
335 South Main Street
Canandaigua, NY 14424-2118
Phone: (585) 396-5052 Fax: (585) 394-2706
Page 1 of 4
APPLICATION FOR VOLUNTEER MEMBERSHIP
PLEASE PRINT IN BLUE OR BLACK INK ALL INFORMATION REQUESTED ON THIS APPLICATION. ANSWER ALL QUESTIONS
FULLY AND CAREFULLY, ATTACHING ADDITIONAL SHEETS IF NECESSARY. ALL STATEMENTS ARE SUBJECT TO
BACKGROUND VERIFICATION.
PERSONAL SUMMARY
NAME AND ADDRESS
_________________________________________________
LAST FIRST MI
__________________________________________ ARE YOU AT LEAST 18 YEARS OLD? _________________
STREET ADDRESS (Yes/No)
__________________________________________
CITY STATE ZIP DO YOU HAVE A VALID DRIVER’S LICENSE? __________________
(Yes/No)
( )
TELEPHONE NUMBER IF YES: _________________ ______ _________________________
LICENSE NUMBER STATE EXP. DATE
CAN YOU COMMIT TO A MINIMUM OF THREE YEARS OF SERVICE TO THE CANANDAIGUA FIRE DEPARTMENT (First six
months as a probationary member?)
_______________________ IF NO, EXPLAIN ANY PERTINENT FACTORS HERE:
__________________________________________________________________________________________
__________________________________________________________________________________________
OCCUPATION: _____________________________________________________________________________
NAME OF EMPLOYER: _______________________________________________________________________
ARE YOU CURRENTLY, OR HAVE YOU EVER BEEN, A MEMBER OF ANOTHER EMERGENCY SERVICE ORGANIZATION?
__________________
(Yes/No)
PLEASE INDICATE THE TYPE OF SERVICE YOU WISH TO PROVIDE TO THE CANANDAIGUA FIRE DEPARTMENT:
________ INTERIOR STRUCTURAL FIREFIGHTER
________ EXTERIOR SUPPORT FIREFIGHTER
________ FIRE POLICE (MUST TAKE OR HAVE EXTERIOR SUPPORT FIREFIGHTER TRAINING)
CITY OF CANANDAIGUA
FIRE DEPARTMENT
Fire Chief Frank Magnera
335 South Main Street
Canandaigua, NY 14424-2118
Phone: (585) 396-5052 Fax: (585) 394-2706
Page 2 of 4
RESIDENCE HISTORY
HOW LONG HAVE YOU RESIDED IN THE CANANDAIGUA AREA? ______________________________________
IF YOU HAVE LIVED AT YOUR CURRENT ADDRESS FOR LESS THAN ONE YEAR, PLEASE LIST BELOW YOUR PREVIOUS
RESIDENCE(S) DURING THAT YEAR:
STREET ADDRESS: ______________________________________ FROM WHEN TO WHEN? __________
CITY STATE ZIP (Mo/Yr-Mo/Yr)
STREET ADDRESS: ______________________________________ FROM WHEN TO WHEN? __________
CITY STATE ZIP (Mo/Yr-Mo/Yr)
EMPLOYMENT HISTORY
BEGINNING WITH THE MOST RECENT, PLEASE LIST BELOW ALL EMPLOYERS WITHIN THE PAST TWO YEARS:
EMPLOYER ___________________________________ STREET ADDRESS __________________________
SUPERVISOR _________________________________ CITY/STATE/ZIP _____________________________
TELEPHONE NUMBER ___________________________ YOUR POSITION ___________________________
EMPLOYER ___________________________________ STREET ADDRESS __________________________
SUPERVISOR _________________________________ CITY/STATE/ZIP _____________________________
TELEPHONE NUMBER ___________________________ YOUR POSITION ___________________________
EMPLOYER ___________________________________ STREET ADDRESS __________________________
SUPERVISOR _________________________________ CITY/STATE/ZIP _____________________________
TELEPHONE NUMBER ___________________________ YOUR POSITION ___________________________
EDUCATION
PLEASE LIST THE SCHOOLS AND COLLEGES YOU HAVE ATTENDED:
HIGH SCHOOL ______________________________________________________________________________________
SCHOOL CITY STATE YEAR OF GRADUATION
COLLEGES/TECHNICAL SCHOOLS
______________________________________________________________________________________________
SCHOOL CITY STATE YEAR GRADUATED DEGREE
______________________________________________________________________________________________
SCHOOL CITY STATE YEAR GRADUATED DEGR
CITY OF CANANDAIGUA
FIRE DEPARTMENT
Fire Chief Frank Magnera
335 South Main Street
Canandaigua, NY 14424-2118
Phone: (585) 396-5052 Fax: (585) 394-2706
Page 3 of 4
EMERGENCY SERVICES RECORD
PLEASE LIST ALL CURRENT AND PAST EMERGENCY SERVICES AFFILIATIONS. CONTINUE ON SEPARATE SHEET TO FULLY
ACCOUNT FOR ALL SERVICES.
DEPARTMENT _____________________________________ YOUR POSITION _________________________
CITY _______________________ STATE______________ TELEPHONE NUMBER ____________________
CHIEF OFFICER (REQUIRED) ________________________ LENGTH OF SERVICE ___________________
FROM/TO
CURRENTLY A MEMBER? ____________________________
DEPARTMENT _____________________________________ YOUR POSITION _________________________
CITY _______________________ STATE______________ TELEPHONE NUMBER ____________________
CHIEF OFFICER (REQUIRED) ________________________ LENGTH OF SERVICE ___________________
FROM/TO
CURRENTLY A MEMBER? ____________________________
DEPARTMENT _____________________________________ YOUR POSITION _________________________
CITY _______________________ STATE______________ TELEPHONE NUMBER ____________________
CHIEF OFFICER (REQUIRED) ________________________ LENGTH OF SERVICE ___________________
FROM/TO
CURRENTLY A MEMBER? ____________________________
TRAINING
PLEASE PROVIDE CERTIFICATION COPIES OF ALL TRAINING COURSES IN EMERGENCY SERVICE ORGANIZATIONS THAT
YOU HAVE COMPLETED, THE DATES COMPLETED AND THE LOCATIONS THE COURSES WERE TAKEN.
EMERGENCY CONTACT
PLEASE LIST PERSON TO BE NOTIFIED IN CASE OF AN EMERGENCY:
NAME/RELATIONSHIP _________________________________________________________
ADDRESS ___________________________________________________________________
CITY/STATE _________________________________________________________________
TELEPHONE NUMBER (_____) ___________________ (_____) _____________________
CITY OF CANANDAIGUA
FIRE DEPARTMENT
Fire Chief Frank Magnera
335 South Main Street
Canandaigua, NY 14424-2118
Phone: (585) 396-5052 Fax: (585) 394-2706
Page 4 of 4
PLEASE RESPOND TO EACH OF THE FOLLOWING QUESTIONS
HAVE YOU EVER BEEN CONVICTED OF ANY CRIME (Felony and/or Misdemeanor)? __________________
Yes/No
HAVE YOU EVER BEEN CONVICTED OF ARSON? __________________
Yes/No
ARE YOU NOW UNDER CHARGES FOR ANY CRIME? _________________
Yes/No
HAVE YOU EVER BEEN DISMISSED FROM ANY PUBLIC OR EMERGENCY RELATED SERVICE, OTHER THAN FOR LACK OF
WORK OR LACK OF FUNDS?
_________________
Yes/No
HAVE YOU EVER RESIGNED FROM ANY PUBLIC OR EMERGENCY RELATED SERVICE RATHER THAN FACE DISMISSAL?
_________________
Yes/No
IF YOU ANSWERED YES TO ANY OF THE QUESTIONS IN THIS SECTION, PLEASE PROVIDE SPECIFICS ON A SEPARATE PAGE.
YOU MUST ALSO COMPLETE AND SIGN THE ATTACHED NYS DCJS -VFF FORM FOR THE CRIMINAL BACKGROUND CHECK.
CERTIFICATION AND AUTHORIZATION
I HEREBY MAKE APPLICATION FOR VOLUNTEER MEMBERSHIP IN THE CITY OF CANANDAIGUA FIRE DEPARTMENT. IF
ACCEPTED, I AGREE TO OBEY THE RULES AND REGULATIONS OF THE CANANDAIGUA FIRE DEPARTMENT AND TO
COMPLETE MANDATORY BASIC TRAINING AND A MINIMUM SIX MONTH PROBATIONARY PERIOD. I UNDERSTAND THAT I
MAY BE DISMISSED AT ANY TIME DURING THIS PROBATIONARY PERIOD AT THE DEPARTMENT’S DISCRETION.
I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM AND ON ALL OTHER APPLICATION MATERIALS SUBMITTED IS
TRUE TO THE BEST OF MY KNOWLEDGE AND AUTHORIZE THE CANANDAIGUA FIRE DEPARTMENT TO CONTACT THE
INDIVIDUALS, ORGANIZATIONS AND EMPLOYERS LISTED TO HELP ASSESS MY SUITABILITY FOR VOLUNTEER MEMBERSHIP.
I UNDERSTAND THAT OFFERING A FALSE DOCUMENT FOR FILING IS A VIOLATION OF NEW YORK STATE PENAL LAW, AND
THAT DISCOVERY OF FALSIFIED INFORMATION WILL BE CAUSE FOR DENIAL OF THIS APPLICATION OR TERMINATION OF
MY MEMBERSHIP.
____________________________________________ __________________
SIGNATURE DATE
UPDATE 6/2018
NEW YORK STATE DIVISION OF CRIMINAL JUSTICE SERVICES
Office of Criminal Justice Operations
Volunteer Firefighter Inquiry Form
INSTRUCTIONS: This form is to be used only by a Sheriff’s Office (or OFPC, where
applicable) when performing searches authorized under NY Executive Law §837-o in
connection with individuals seeking membership in a Volunteer Fire Department.
This form must be U.S. mailed, faxed or hand delivered between agencies. E-mail
transmission is not permissible.
Shaded boxes are required data elements.
A. DATE:
B. REQUESTING VOLUNTEER FIRE DEPARTMENT
DEPARTMENT NAME:
FIRE CHIEF NAME: SIGNATURE:
ADDRESS:
TELEPHONE NUMBER: FAX NUMBER:
1. NAME (LAST, FIRST, MIDDLE)
2. ADDRESS (Street, City, Zip Code)
3. ALIAS AND/OR MAIDEN NAME 4. SEX
M F
5. RACIAL APPEARANCE
White Black Indian Asian Unknown Other
6. ETHNICITY
Hispanic Not Hispanic Unknown
7. HEIGHT
Ft. In.
8. DATE OF BIRTH
Month Day Year
9. PLACE OF BIRTH
10. SOCIAL SECURITY NO.
RESULTS OF INQUIRY
INVESTIGATING OFFICER: _______________________________________________________ DATE ___________________
(PRINT NAME/TITLE)
INVESTIGATING OFFICER SIGNATURE ______________________________________________________________________
NO RECORD OF AN ARSON CONVICTION OR A CONVICTION REQUIRING REGISTRATION AS A SEX OFFENDER
CONVICTED OF ARSON; NO RECORD OF A CONVICTION REQUIRING REGISTRATION AS A SEX OFFENDER
CONVICTED OF A CRIME REQUIRING REGISTRATION AS A SEX OFFENDER; NO RECORD OF AN ARSON CONVICTION
CONVICTED OF ARSON AND CONVICTED OF A CRIME REQUIRING REGISTRATION AS A SEX OFFENDER
DCJS-VFF (12/14)
Canandaigua Fire Department
Frank Magnera
335 South Main Street
Canandaigua, NY 14424
(585) 396-5052
(585) 394-2706
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CITY OF CANANDAIGUA FIRE DEPARTMENT APPLICATION FOR VOLUNTEER (City of Canandaigua)

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Completed 6 July 2022

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