1. law, govt and politics
2. law enforcement
3. fire department

STAMFORD VOLUNTEER FIREFIGHTERS ASSOCIATION
[APPLICATION FOR MEMBERSHIP]
PLEASE SPECIFY DEPARTMENT PREFERENCE:
Belltown____
Glenbrook____
Long Ridge____
Springdale ____
________________________________________
Applicant Name (Last, First, MI)
M / F
Gender
____/_____/_____
Date of Birth
_________________________________________
Address
______________
Apt. or Unit #
_________________________________________
City
__________
State
(MM/DD/YYYY)
_____________________
Zip Code
How long have you lived at this address? ______________________
Home Phone
__(_______)__________________
Driver’s License Number
Are you a U.S. citizen?
Cell Phone
_______________________________
Yes_______
__(_______)__________________
State issued
________________
No________
If no, are you legally authorized to live and work in the United States?
Yes_____
(Applicant must provide copies of applicable U.S. Immigration and Naturalization Service documentation)
No______
EDUCATION
_________________________ _______________________________ ________________________
Highest Level of Education
Name of High School
Date of Graduation (MM/YYYY)
_________________________________________________________
Name of College
________________________
Date of Graduation (MM/YYYY)
EMPLOYMENT
______________________________________ ____________________________________________
Current Employer
Employer Address (include City and State)
______________________________________ _(_____)_____________________________________
Supervisor Name
Supervisor Phone Number
Page 1 of 7
STAMFORD VOLUNTEER FIREFIGHTERS ASSOCIATION
[APPLICATION FOR MEMBERSHIP]
FIRE SERVICE EXPERIENCE
Are you now or have you ever been a member of another Fire Department?
_________________________________________
Department Name
Are you a certified firefighter? Yes____ No____
State in which you were certified _______
Yes_____
No_____
__________________________________
Reason for Leaving
Certified EMT/EMR?
Date certified
Yes_____
No_____
Fire___/___/_____ EMS___/___/______
MILITARY SERVICE
_________________________________________
Branch
________________________________
Date Served
__________________________________________
Type of Discharge
CRIMINAL HISTORY
Have you ever been arrested? Yes_____
No_____
Have you ever been convicted of a criminal offense? Yes____
No ____
If so, please explain the nature and disposition of any criminal convictions including the date and
location of all offenses
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Page 2 of 7
STAMFORD VOLUNTEER FIREFIGHTERS ASSOCIATION
[APPLICATION FOR MEMBERSHIP]
REFERENCES
Please provide three references to which you are not related.
________________________________________
Name
_______________________________
Telephone
________________________________
_________________________
________________________________________
Name
________________________________
Telephone
Relationship
Years Known
________________________________
_________________________
________________________________________
Name
________________________________
Telephone
Relationship
________________________________
Relationship
Years Known
_________________________
Years Known
I hereby certify that the information I have given in this application is true and correct to the
best of my knowledge and I understand that any falsification may result in my expulsion from
any of the associated Stamford Volunteer Fire Companies if elected to the aforementioned. I
hereby agree to adhere to the Bylaws and Standard Operating Procedures set forth by the
department. If removed from the Department I hereby agree to return all equipment issued to
me by the department including, but not limited to all fire gear, radios, pagers, keys, and
bylaws. I understand that failure to return department equipment following an expulsion or
resignation from the department may result in legal action. I hereby authorize the release of
any and all information concerning me contained in the records of any Federal, State or Local
Police agency to the corresponding entity.
___________________________________________
Applicant Signature
____ /____/_________
Date
Applicants under 18 years of age must have this application signed by a parent or legal guardian
I, the undersigned parent of _____________________________________________ do hereby consent
to his/her proposed membership in the ______________________________ Fire Department.
___________________________________________
Signature of parent or Legal Guardian
____ /____/_________
Date
Page 3 of 7
STAMFORD VOLUNTEER FIREFIGHTERS ASSOCIATION
[APPLICATION FOR MEMBERSHIP]
BACKGROUND CHECK RELEASE FORM
I, _______________________________ (print legal first, middle, last name), hereby authorize
Stamford Volunteer Firefighters Association, and all of its associated Departments, to
investigate my background and qualifications for purposes of evaluating whether I am qualified
for the position for which I am applying.
I understand that the Stamford Volunteer Firefighters Association or each Department may
utilize an outside firm or firms to assist in checking such information, and I specifically authorize
such an investigation by information services and outside entities of the company's choice. I
also understand that I may withhold my permission and that in such a case, no investigation will
be done and my application will not be processed further.
I hereby release, discharge and exonerate the Stamford Volunteer Firefighters Association, its
associated Departments, its agents, representatives, and any person so furnishing information
from any and all liability of every nature and kind arising out of the furnishing, inspection or
collection of such documents, records, and other information or the investigation made by the
Stamford Volunteer Firefighters Association or it’s associated Departments.
_________________________________
________________
Applicant Signature
Date
_________________________________
________________
Print Name
Date of Birth
Page 4 of 7
STAMFORD VOLUNTEER FIREFIGHTERS ASSOCIATION
[APPLICATION FOR MEMBERSHIP]
VOLUNTEER FIRE RESCUE CANDIDATE MEDICAL CLEARANCE
To be completed by volunteer candidate:
Participation as a fire and rescue volunteer involves strenuous physical activities which require strength
and endurance. You will be allowed to participate in these activities only if you have been examined by a
physician who certifies that you are in good health and physically fit. The fire department you have
chosen to join has no knowledge of your physical condition or abilities and must therefore rely upon
your representation and the representation of your physician that you are healthy enough to participate
in firefighting activities. Your signature below indicates that you fully understand what these activities
are and that no significant changes have occurred in your medical condition since you were examined by
the physician whose signature appears on this form.
_________________________________
________________
Applicant Signature
Date
_________________________________
________________
Print Name
Date of Birth
Page 5 of 7
STAMFORD VOLUNTEER FIREFIGHTERS ASSOCIATION
[APPLICATION FOR MEMBERSHIP]
VOLUNTEER FIRE RESCUE CANDIDATE MEDICAL CLEARANCE
To be completed by physician’s office:
I have reviewed the accompanying “Physicians’ Guidance Regarding Medical Clearance as a Fire Rescue
Volunteer.” I have examined the above individual, reviewed his/her medical history, and make the
following recommendations for his/her participation as a volunteer firefighter:
____ Full Participation
____ Limited Participation
____ No Participation
____ Additional Evaluation Required
If not full participation, please provide limitations:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Physician Name: ________________________________________________
Address:
_____________________________________________________
City: _____________________________
State: _______
Zip Code: ________________
Telephone: __(____)____________________
Physician Signature: _______________________________
Date:____/_____/__________
Page 6 of 7
STAMFORD VOLUNTEER FIREFIGHTERS ASSOCIATION
[APPLICATION FOR MEMBERSHIP]
VOLUNTEER FIRE RESCUE CANDIDATE MEDICAL CLEARANCE
PHYSICIANS’ GUIDANCE REGARDING MEDICAL CLEARANCE FOR FIRE RESCUE VOLUNTEERS
Firefighting and emergency medical response remain some of the most dangerous occupations in the
United States. As a fire and rescue volunteer this candidate will face a number of challenging situations
and will be expected to be able to perform their duty under highly stressful and physically demanding
conditions that include:
Regularly wearing personal protective equipment weighing up to 75 lbs. for long periods
Working in hot and smoky environments
Working with hand tools, power equipment and hoses for long periods
Climbing stairs and ladders
Exposure to inclement weather for long periods
Regularly lifting weight up to 150 lbs
To help ensure that this candidate is in good health and capable of performing the duties required your
examination should verify that they have:
Normal pulse and blood pressure
Normal breathing
Normal hearing
Normal eyesight (with corrections as necessary)
Normal muscular flexibility and manual dexterity
No significant skeletal deformities
No other debilitating diseases or conditions
Any further questions you have regarding this physical examination should be directed to the Volunteer
Firefighter Recruitment Coordinator at 203-998-5911.
Page 7 of 7