ONLINE BUNK IN APPLICATION

Bunk-In Application

First Name

Last Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Phone

Birthday

Drivers License Number

Drivers License State

Emergency Contact Information

Name

Relationship

Address

Primary Phone

Alternate Phone

Home Organization Information

Department Name

Department Address

Have you ever been subject to disciplinary action in this or any organiation?

Yes

Department Phone Number

Chief

Do you have any experience driving fire apparatus?

Yes

Training Information

Have you completed firefighter 1 or equivalent?

Yes

Have you completed NYS Haz-Mat awareness or equivalent?

Yes

Do you posses a CPR certification?

Yes

Do you posses a NYS EMT-B or higher?

Yes

If yes, provide expiration date.

If yes, provide state EMT number and expiration date.

Background Information

Please list the name(s) of any aquaintences or former bunk-ins of the Taunton Fire Department if any.

Name

Have you ever been convicted of or plead guilty to a felony or arson charge or a reduction of one of these offenses?

Yes

Are you aware of any injury, medical condition(s) or physical condition(s) that may limit or impair your ability to actively participate and perform duties as a firefighter bunk-in.

Yes

OSHA regulations require that you pass a physical examination. Are you able to provide a copy of a physical or willing to undergo a medical examination?

Yes

Personal Reference

Personal Reference Phone Number

Years known

Personal Reference

Personal Reference Phone Number

Years known

EQUAL EMPLOYMENT OPPORTUNITY

The Taunton Fire Department values diversity in the workplace. Men and women of all ages, cultural and ethnic backgrounds, religious and political affiliations, national origins, and persons with disabilities are encouraged to apply and will not be discriminated against.

PRIVACY NOTICE

Section 94 of the Public Offenders Law (Personal Privacy Protection Law) requires that you be notified of the following facts when information which will be maintained in a record system is collected from you. The authority to request and confirm this information about you is found in Article 6 of the Executive Law. The information obtained will be used to determine your qualifications for the position you are applying and be maintained in your personal file (if you become a fire department member) or in our application file for six months (if you are not accepted as a member).

Failure to provide the information or authorization will result in your application not being considered for membership.

All information contained or obtained herein will remain confidential and will only be used for internal membership processing.

CERTIFICATION AND AUTHORIZATION

I hereby certify that the statements herein are true and correct to the best of my knowledge. I hereby authorize the Taunton Fire Department and its duly authorized representatives to conduct a thorough and comprehensive background investigation of my personal life and work history, in order to determine my suitability for membership. I understand that should any information given on, or as a result of this application, be false, misleading, or erroneous it may result in the rejection of my application for membership, or in my discharge from the Taunton Fire Department. By signing this application I am granting the Taunton Fire Department access to all records and I authorize the release of all information held by an individual or organization.

I certify that I have read and I fully understand this application. I also certify that all the information is true and complete to the best of my knowledge.

Your Signature

Thanks for applying!We’ll get back to you soon.