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| Applicant Information |
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| Last Name:
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| First Name:
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| Middle Initial:
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| Date of Birth:
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| House Number:
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| Address:
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| Apt. / Suite Number:
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| Town:
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| State:
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| Zip Code:
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| Home Telephone Number:
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| Mobile Number:
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| E-Mail Address:
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| Date of Application:
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| Can You Commit to a Minimum of 3 Years' Service with the Bedford Village Fire Deptment? :
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| Membership Status |
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| Category to be applied for:
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| Emergency Contact Information |
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| (EC) Name:
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| (EC) Address:
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| (EC) Primary Number:
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| (EC) Secondary Number:
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| Relationship to You:
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| Personal Information |
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| Are You a Citizen of the United States?:
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| If not, what is Your Residency Status? :
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| If not a citizen, provide a copy of relevant documentation:
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| Do you current possess a driver's license? :
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| License State:
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| License Class:
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| License Number:
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| License Expiration Date:
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| Copy of Drivers License:
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| Do you have a social networking account (E.g., Facebook, Instagram, Twitter)? If so, please list:
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| Employment History |
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| Please list your employment history for the last five years. Indicate if you are currently not employed.
(Use a separate sheet of paper, if necessary / indicate if you are a full-time student)
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| (EH) Name:
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| (EH) Address:
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| (EH) You're Position:
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| (EH) Supervisor:
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| (EH) Phone Number:
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| (EH) Dates of Employment:
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| (EH-1) Name:
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| (EH-1) Address:
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| (EH-1) You're position:
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| (EH-1) Supervisor:
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| (EH-1) Phone Number:
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| (EH-1) Dates of Emplyoment:
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| Additional Employments:
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| Education |
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| High School :
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| Did You Graduate High School:
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| College:
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| Did You Graduate College:
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| Graduate:
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| Did you Graduate Graduate School:
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| If you are not presently enrolled in college, do you have plans to enroll in a college or university? :
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| Please Explain:
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| Military Service |
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| Have You Served in the U.S. Armed Force:
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| If so, What Branch:
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| Years of Military Service:
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| Discharge Status:
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| Reserve Status:
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| Did You Receive Special Training that Might be Applied to the Fire Department:
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| Fire Department Status |
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| Are you now or have you ever been a member of a paid or volunteer fire department or volunteer ambulance service:
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| If Yes, Which Department:
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| Years of Service:
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| Reason for Leaving:
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| Personal References |
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| Please list three personal references (other than members of the Bedford Village Fire Department) to whom we may inquire as to your character |
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| (PR) Name:
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| (PR) Address:
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| (PR) Relationship to You:
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| (PR) Phone Number:
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| (PR) E-Mail Address:
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| (PR-1) Name:
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| (PR-1) Address:
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| (PR-1) Relationship to You:
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| (PR-1) Phone Number:
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| (PR-1) E-Mail Address:
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| (PR-2) Name:
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| (PR-2) Address:
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| (PR-2) Relationship to You:
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| (PR-2) Phone Number:
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| (PR-2) E-Mail Address:
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| Also list the names of any acquaintances who are members of the Bedford Village Fire Department:
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| Background Information |
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| Have you ever been convicted of or pled guilty to a felony, misdemeanor, insurance fraud, arson, sexual misconduct, perjury, excluding offenses where the record has been sealed, purged, or where you have been exonerated? :
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| Are there any criminal charges pending against you? :
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| Are there any moving violations noted on your current driver's license? :
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| If you answered "yes" to any of the above, please explain :
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| Following acceptance of an application for membership to the BVFD, an applicant is required to undergo a physical examination by a physician designated by the District, to determine the applicant's ability to perform the duties of a Firefighter / EMT |
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| If you are accepted for membership will you agree to undergo this examination:
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| Attached Forms |
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| Affirmation of the Applicant & Authorization for Release of Information Form:
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| Status |
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| Application Status:
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| Application Status Date:
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Click the following to download the Affirmation of the Applicant & Authorization for Release of Information Form
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