2. PERSONAL INFORMATION
4. First Name*
5. Last Name*
6. Date of Birth*
   Date of Birth
7. Last 4 Digits of SSN*
9. Street Number*
10. Street Name*
11. Street Type*
12. Apt #
14. Subdivision
15. City*
16. State*
17. Zip*
19. Daytime Phone Number*
20. Evening Phone Number*
21. Email Address*
23. Hair*
24. Eyes*
25. Scars*
27. Drivers License Number*
28. State*
29. Type/Class*
31. TYPE OF MEMBERSHIP
33. Which SVFD membership type do you have an interest in pursuing?*

    1. Regular Membership (Fire Suppression, Firefighter, First Responder) - Must be 18+ years old
    2. Junior Membership - 16 or 17 years old
    3. Associate Membership - 21+ years old or older
35. EMERGENCY CONTACT INFORMATION
37. First Name*
38. Last Name*
39. Relationship*
41. Street Address
43. City
44. State
45. Zip
47. Daytime Phone Number*
48. Evening Phone Number*
50. Primary Care Physician
51. Physician's Phone Number
53. FIRE FIGHTING & EMERGENCY MEDICAL SERVICE EXPERIENCE
55. Organization
56. How Long?
58. Street Address
60. City
61. State
62. Zip
64. Date you entered
65. Date you left
67. Reason for leaving
69. Rank or Positions Held
71. Supervisor's Name
72. Supervisor's Phone Number
76. Organization
77. How Long?
79. Street Address
81. Street Address
83. City
84. State
85. Zip
87. Date you entered
88. Date you left
90. Reason for leaving
92. Rank or Positions Held
94. Supervisor's Name
95. Supervisor's Phone Number
99. Organization
100. How Long?
102. Street Address
104. City
105. State
106. Zip
108. Date you entered
109. Date you left
111. Reason for leaving
113. Rank or Positions Held
115. Supervisor's Name
116. Supervisor's Phone Number
118. List previous Emergency Medical Service affiliation and training with inclusive dates (list highest level of training, expiration date of certification and organization):
120. List any or all other volunteer organizations you are or have been a member of (NAME and LOCATION)
122. Please tell us briefly why you would like to become a member of the Seabrook Volunteer Fire Department
124. EMPLOYMENT HISTORY
     List below all previous employers in the last 5 years starting with the most current. Use additional paper if necessary.
126. Current Employer
128. Position Held
129. How Long?
131. Street Address
132. City
134. State
135. Zip
136. Business Phone Number
138. Supervisor's Name
139. Supervisor's Phone Number
143. Previous Employer
145. Position Held
146. How Long?
148. Street Address
149. City
151. State
152. Zip
153. Business Phone Number
155. Supervisor's Name
156. Supervisor's Phone Number
158. REFERENCES
     Please list three character references
160. First Name
161. Last Name
163. Street Address
164. City
166. State
167. Zip
168. Daytime Phone Number
170. Occupation
171. Work Phone Number
175. First Name
176. Last Name
178. Street Address
179. City
181. State
182. Zip
183. Daytime Phone Number
185. Occupation
186. Work Phone Number
190. First Name
191. Last Name
193. Street Address
194. City
196. State
197. Zip
198. Daytime Phone Number
200. Occupation
201. Work Phone Number
203. CRIMINAL HISTORY
205. Within the last three years have you been convicted of a Felony or Misdemeanor including moving traffic violations?*

     1. Yes
     2. No
207. Do you have a Felony or Misdemeanor Case (including moving traffic violations) pending?*

     1. Yes
     2. No
209. Have you ever forfeited a bond?*

     1. Yes
     2. No
211. If YES to the criminal history questions, explain in detail below. Use additional paper is necessary.
213. MEDICAL HISTORY
215. Have you ever been diagnosed as, or been treated for having any of the following?

     Please check all that apply

     1. Diabetes
     2. Emphysema
     3. Tuberculosis
     4. Epilepsy
     5. Cerebral Palsy
     6. Nervous Disorders

     1. Cardiovascular Problems (Heart Disease)
     2. Cerobrovascular Accident (Stroke)
     3. Eyesight Defect
     4. Hearing Defects
     5. Lifting Restrictions
217. Do you have a physical or mental disorder which may impair your ability as a fire fighter or first responder?
219. If YES to any of these questions, explain in detail below. Use additional paper if necessary.
221. I, hereby make application for membership in the Seabrook Volunteer Fire Department.*

     By submitting this online form, I hereby affirm that all the foregoing statements on this application are true and correct. It is understood that a false statement on this application may be considered as sufficient cause for rejection or, if application is approved, dismisal from the Seabrook Volunteer Fire Department.

     1. YES
     2. NO
Leave This Blank:


223. 1. Receive an email copy of this form.
224. Email address

     This field is not part of the form submission.

225. Submit

* indicates a required field