South Meriden Volunteer Fire Department, Inc.
31 Camp St, PO Box 3030, South Meriden, CT 06451
WE TEST AND MAINTAIN A DRUG FREE DEPARTMENT
APPLICATION FOR MEMBERSHIP
(PLEASE PRINT)
NAME: _____________________________________________ AGE AT (Last Birthday): _______________
Optional
ADDRESS: __________________________________________ HOME TEL_________________ CELL:_________________
YEARS AT PRESENT ADDRESS: _______________ YEARS SOUTH MERIDEN RESIDENT: ____________
PREVIOUS ADDRESS: ___________________________________________ STATE: __________ ZIP: ___________
YEARS AT PREVIOUS ADDRESS: ______________ DATE OF BIRTH: ______/______/_______
Optional
SOCIAL SECURITY NO.: _______-______-________ BLOOD (TYPE IF KNOWN): __________
VALID CONNECTICUT DRIVER’S LICENSE #: _______________________EXP DATE: ___/___/__ LICENSE CLASS: _________
NEXT OF KIN: ______________ RELATIONSHIP: ____________ TELEPHONE: ____________CELL _____________
DO YOU HAVE A CAR THAT YOU WILL BE ABLE TO RESPOND TO DUTY ASSIGNEMNTS: _______________
EMPLOYMENT HISTORY
BEGIN WITH PRESENT OR MOST RECENT EMPLOYMENT AND WORK BACKWARDS FOR THE PAST 10 YEARS.
IF ADDITIONAL SPACE IS REQUIRED, ATTACH AN ADDITIONAL SHEET USING THE SAME FORMAT.
Dates
Name of Employer
Address/City
Type of
Business
Title & Duties
Shift &
Hrs
EDUCATION
PLEASE LIST ALL SCHOOLS ATTENDED (INC. HIGH SCHOOL, COLLEGE & TRADE SCHOOLS. IF
ADDITIONAL SPACE IS REQUIRED, ATTACH AN ADDITIONAL SHEET USING THE SAME FORMAT.
Proof of HS Graduation or GED will be required
Date
Name of School
Major
Subject
Grad
Y/N
PAST EXPERIENCE IN FIREFIGHTING OR EMERGENCY MEDICAL SERVICE
PLEASE LIST YOUR PRESENT OR PAST ORGANIZATIONS WITH A CONTACT PERSON ALONG WITH ANY
CERTIFICATIONS YOU MIGHT HAVE.
Name of Group
Dates of Involvement
Telephone
Contact
Certifications
REFERENCES
GIVE THREE PERSONS THAT HAVE KNOWN YOU FOR AT LEAST [ 5 ] YEARS, THAT ARE NOT RELATIVES.
Name
Address
Telephone
Years Known
Occupation
ADDITIONAL INFORMATION
LIST OTHER ORGANIZATIONS YOU HOLD MEMBERSHIP IN: __________________________________________
______________________________________________________________________________________________________
HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENSE and/or AN OFFENSE AGAINST MILITARY LAW
OR ARE THERE ANY CRIMINAL CHARGES CURRENTLY PENDING AGAINST YOU? YES [ ] NO [ ]
IF YES EXPLAIN:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
REASON WANTING TO JOIN FIRE COMPANY: ___________________________________________________________
________________________________________________________________________________________________________
DATE OF LAST PHYSICAL EXAM: ________________ PHYSICAL LIMITATIONS: _____________________________
________________________________________________________________________________________________________
HAVE YOU TESTED FOR OR ARE YOU ON AN EMPLOYMENT LIST FOR CAREER FIRE FIGHTERS POSITION?
YES [ ] NO [ ] IF YES EXPLAIN: ______________________________________________________________
TYPE OF MEMBERSHIP APPLYING FOR: ACTIVE F/F [ ] ASSOCIATE [ ]
I do hereby swear that the information on this application to be true to the best of my knowledge and, therefore, do wish to attain
membership in the South Meriden Volunteer Fire Department. I agree if accepted when there is an opening after passing all stages of the
application process to attend Meetings & Department functions if an Associate Member, and if I am accepted as an Active Firefighter to meet
all Quotas for Calls, Drills, General Meetings, Duty Squad obligations and to conform to all Standard Operating Procedures (SOP), Standard
Operating Guidelines (SOG), Station Rules, State & Federal Regulations and Guidelines and SMVFD department By-Laws. Any False
information given on this application will be grounds for termination of the application process and or termination of membership in SMVFD
if I have already been accepted in SMVFD immediately.
By signing below I give the SMVFD, the City of Meriden and its agent’s permission to do a full police background check / screening on me. I
also understand that this information will be used for the purpose to verify the information on this application for membership. I give
permission to all State, Federal, local Police agencies, past and present employers and references to release all information about any or all
records and information that they have or know about myself. I will hold harmless the SMVFD, City of Meriden and all agencies, past and
present employers and references for the release of this information.
APPLICANT’S SIGNATURE: ________________________________ APPLICATION DATE: _______________________
Written Exam Date & Score: ____/_____/____ ______%
Background & Reference Check Clearance Date: ____/____/____
Agility Test Date & Disposition: ____/____/____ Pass [ ] Fail [ ]
Oral Interview Date & Score: ____/____/____ _________% Physical Examination Date & Disposition: ____/____/____ Pass [ ] Fail [ ]
Acceptance or Denial Company Date: ____/____/____ Acceptance [ ] Denial [ ]
Revised 1/2017
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