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)
