Germantown Volunteer Fire Department 20001 Crystal Rock Drive Germantown, Maryland 20874 Station 29: 240-773-4729 Admin Office: 240-773-8989 www.gvfd29.org

Membership Committee Use Only Date Rec’d: ________________ Complete: _________________ Initials: ____________________

Application for Membership The Germantown Volunteer Fire Department, Inc. values diversity in the workplace. Men and Woman of all ages, cultural and ethnic backgrounds, religious and political affiliation, national origin, and person with disabilities are encouraged to apply. To apply, please complete and submit this official application form. The application shall be completed in full. We may wish to contact you by mail, telephone, and/or email. It is your responsibility to make sure contact information is correct and current. Except to accommodate the needs of individuals with disabilities, committee members cannot complete or change any information on the application. Any changes must be made by the applicant in person or through signed written communication.

Personal Information Membership Category Desired (Please see page 6 for description):

Firefighter/Rescuer

EMS

Administrative

Full Name: _________________________________________________________________________________________ (First Middle Last)

Nickname/Preferred Name: __________________________________________________________________________ Home Address: _____________________________________________________________________________________ City: _________________________________ State: ________________________________ Zip: _________________ Home Phone: ________________________________ Cell Phone: ___________________________________________ Email: ______________________________________ Date of Birth: _________________________________________ (Required)

Are you a citizen of the United States? If No, How old are you? _______________

Yes

No

Are you at least 18 years old?

Yes

No

Current Occupation: ______________________________________

Driver's License Number: ____________________________________ State: __________________ Class: _________ Has your driver's license ever been suspended and/or revoked? Yes No If yes, please provide details and dates: __________________________________________________________________ ___________________________________________________________________________________________________ Have you ever been convicted of, or have you ever pled guilty or nolo contendre (no contest) to, a crime other than a minor traffic citation in court? Yes No If yes, please provide details, where, and what was the outcome? ____________________________________________ ___________________________________________________________________________________________________

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Please list any special skills, your interests, hobbies: _______________________________________________________ ___________________________________________________________________________________________________ In two to three sentences, please tell us why you would like to join Germantown Vol. Fire Department: ____________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

Emergency Contact Information Name: _______________________________________________ Relationship: ________________________________ Address: ___________________________________________________________________________________________ City: ______________________________________ State: _______________________ Zip: _____________________ Home Phone: ____________________________________ Cell Phone: _______________________________________

Education Name of Last High School Attended: ___________________________________________________________________ City: _______________________________________________ State: _________________________________________ Last Grade Completed: ________ Diploma Received? Yes No Date of Graduation: ___________________________ Name of College of University: _________________________________________________________________________ City: _______________________________________________ State: _________________________________________ Credit or Degree(s) Earned? __________________________________________________________________________ Foreign Languages Spoken/Read?______________________________________________________________________ Relevant training you would like to make the committee aware of? __________________________________________ ___________________________________________________________________________________________________

Employment Current Employer: ______________________________________________ Dates Employed: _________ to_________ Address: ___________________________________________________________________________________________ City: _________________________________ State: ________________________________ Zip: _________________ Contact Person: ____________________________________________ Phone: _________________________________

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Email: _______________________________________________ Previous Employer: ______________________________________________ Dates Employed: _________ to________ Address: ___________________________________________________________________________________________ City: _________________________________ State: ________________________________ Zip: _________________ Contact Person: ____________________________________________ Phone: _________________________________ Email: _______________________________________________ Previous Employer: ______________________________________________ Dates Employed: _________ to________ Address: ___________________________________________________________________________________________ City: _________________________________ State: ________________________________ Zip: _________________ Contact Person: ____________________________________________ Phone: _________________________________ Email: _______________________________________________

Fire/Rescue/EMS Experience Have you ever applied to GVFD?

Yes

No

If yes, date applied? _______________________

Have you ever applied to another fire/rescue/ems department/squad? Yes No If yes, please list the department(s) which you have applied to, the date applied, and the outcome: _______________ ___________________________________________________________________________________________________ Have you ever served in another fire/rescue/ems department/squad? Yes No If yes, please answer below. The Chief of the department must be contacted before being scheduled for an interview. Department: ______________________________________________ Dates of Service: ___________ to___________ Address: ___________________________________________________________________________________________ City: _________________________________ State: ________________________________ Zip: _________________ Chief's Name: ____________________________________________ Phone: __________________________________ Email: ____________________________________________ Highest rank held: _______________________________ (Required)

Reason why you left? ________________________________________________________________________________ (Required)

Fire/Rescue courses taken: ____________________________________________________________________________ Fire/Rescue vehicles authorized to operate: ______________________________________________________________

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References Please list three character references who you have known for at least three years. References cannot be employers and cannot be related to you. Please provide all information asked for and print clearly and neatly. All references will be contacted by the committee and the committee will need to receive a response from the reference before scheduling the applicant for an interview. Name: _______________________________________________________ Years Known: ________________________ Address: ___________________________________________________________________________________________ City: ______________________________________ State: _______________________ Zip: _____________________ Home Phone: _____________________________ Email: __________________________________________________ (Required)

Name: _______________________________________________________ Years Known: ________________________ Address: ___________________________________________________________________________________________ City: ______________________________________ State: _______________________ Zip: _____________________ Home Phone: _____________________________ Email: __________________________________________________ (Required)

Name: _______________________________________________________ Years Known: ________________________ Address: ___________________________________________________________________________________________ City: ______________________________________ State: _______________________ Zip: _____________________ Home Phone: _____________________________ Email: __________________________________________________ (Required)

Important Facts to Consider Time commitment. Volunteering with GVFD or any other station in the county requires a very significant time commitment on the applicant's part. Station standby time requirements amount to a minimum of 32 hours a month. All volunteers will be asked identify a weeknight standby and one weekend standby a month. A minimum of 5 hours each week and 10 hours one day, per weekend, per month. Training at the Public Service Training Academy (PSTA) and station will add to these hours. Members are required to attend a monthly business meeting, and will frequently be asked to help out with community events. Meeting such time requirements needs a significant commitment on the part of the applicant and their family/significant others. We strongly encourage that the applicant think about the time commitment in terms of their families and/or significant other to ensure that they have their support and understanding. It is not a glamorous job. Participation with the Fire/Rescue services in not necessarily for everyone. Depiction of the service on television series such as Third Watch, ER, etc..., though often based on real life situations, are not an accurate portrayal of what one necessarily does or observes in the Fire/Rescue Service. The work is physically strenuous, emotionally challenging, and high stress. Service providers have to deal with extremely noisy, dirty, work environments and are exposed to unsightly, disturbing sights on a regular basis. The rewarding aspects of the service is the knowledge of a job well done, having the ability to help someone in need, and often having made a difference in someone's life. It is often a thankless job with few tangible rewards, a lot of training and little recognition. You need to ask yourself if “this is for you?”

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Germantown Volunteer Fire Department

20001 Crystal Rock Drive Germantown, Maryland 20874 Station 29: 240-773-4729 Admin Office: 240-773-8989 www.gvfd29.org

Certification and Authorization I hereby certify that the statements contained herein are true and correct to the best of my knowledge. I understand that should the investigation disclose material misrepresentation, omissions, and/or falsifications, my application may be rejected, or if a member, my membership and all rights and privileges of my membership may be terminated. My signature on this application indicates I have read the job description for the position which I am applying for and I understand that the job of a firefighter/rescuer and/or EMT is physically challenging and that my membership is dependent upon successful completion of a physical examination to be conducted by Montgomery County Occupational Medical Services and a favorable background investigation to be conducted by Montgomery County Fire/Rescue Office of Internal Affairs. This is to certify that I, _______________________________________ (Full name) am an applicant for a Firefighter/Rescuer EMS Administrative (check box) member position with the Germantown Volunteer Fire Department, Inc. and that I do hereby authorize the release of any and all information to the Germantown Volunteer Fire Department, Inc. that they may request, from any of my records or files. Such information may include, but will not be limited to: military records, volunteer records, employment records, education records, criminal records, and transcripts, etc. I also release all persons from any and all liability, which could result from furnishing said information to the Germantown Volunteer Fire Department, Inc., or an agent of the Germantown Volunteer Fire Department, Inc. Further, I authorize the Germantown Volunteer Fire Department Inc. to copy or otherwise reproduce this original document and let such copied or otherwise reproduced copy act as the original document. The original document is to be retained on file with the Germantown Volunteer Fire Department, Inc. and this authorization to release information shall expire from one (1) year of the date signed by me. Further, I authorize the investigation of all statements contained herein, and direct the custodian of any of the records relevant to the confirmation of these to release such information necessary for verification. I further understand that the information obtained by the Germantown Volunteer Fire Department, Inc. during the application process will not be revealed to me should my application be rejected. I have read, or have had read to me the statements above and my signature below agrees to these statements above. Signature of Applicant: _______________________________________________________ Date: ________________ Print Name: ___________________________________________ Signature of Applicant: _______________________________________________________ Date: ________________ (Required for applicant's under the age of 18)

Print Name: ______________________________________ Relationship to Applicant: _________________________

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Categories of Membership Any person eighteen (18) years of age or older, will be eligible for membership in this Department, provided they meet all requirements set by The Membership. Any person between sixteen (16) and eighteen (18) years of age, living in Montgomery County, Maryland, will be eligible for junior membership in the Department provided they have written consent from their parents or legal guardians and meet all requirements set by the Membership. Junior Membership is restricted to positions available.

Fire / Rescue: This category is available for applicants, who wish to serve in all aspects of the Germantown Volunteer Fire Department, including: Firefighter, Emergency Medical Technician, and Paramedic. This category includes manual and technical work in fire suppression, fire prevention, rescue, and emergency medical services involving duties and responsibilities of an emergency and hazardous nature, which may require the highest level of sustained exertion and agility. Work involves exposure to extreme heat, dirt, low visibility and confined spaces, extreme heights, swift and standing water, disease, dismemberment and other unpleasant conditions. Fire and Rescue members will be required to respond to fire alarms and other emergency or service calls and lift, carry, drag, lay and connect hose lines and appliances, hold nozzles and direct fog or water streams, extinguishers, bars, hooks, rope lines, ladders and other emergency equipment as necessary.

Additionally, Fire/Rescue members will be assigned to Emergency Medical Services duties and will be required to lift, carry and transport persons in ambulances and otherwise provide efficient and immediate care to the ill or injured at the scene of an incident and during transport. ALL FIRE/RESCUE MEMBERS ARE REQUIRED TO BE CERTIFIED AS EMERGENCY MEDICAL TECHNICIANS.

EMS: This category is available for applicants who only wish to serve as Emergency Medical Services Personnel including: Emergency Medical Technician and Paramedic. Members will be assigned to Emergency Medical Services duties and will be required to lift, carry and transport persons in ambulances and otherwise provide efficient and immediate care to the ill or injured at the scene of an incident and during transport. EMS members work closely with Fire/ Rescue units and may be exposed to many of the same conditions as listed above but will not be permitted to engage in fire suppression or other technical rescue activities.

Administrative Member: This category is available for applicants who do not wish or may not be able to participate in Fire/Rescue or EMS operations, but still desire to serve their local volunteer fire department. Membership in this category is reserved for persons whose special abilities or skills may be considered beneficial to the Department and/or those who have a desire to participate in fundraising, departmental events, public service events, work details, administrative support and other non-emergency related functions. Administrative members will not be permitted to participate in fire and rescue operations.

Junior Membership: This category is available for prospective applicants between the ages of 16 and 18, has limited availability and is very competitive. Junior members may pursue Fire/Rescue or EMS training and may be eligible to participate in the various fire/rescue and emergency services duties listed above at the discretion of the Fire and Rescue Chief. Parental permission is required to pursue this category of membership and certain restrictions apply to participation while school is in session including curfews and grade point average requirements. Letters of recommendations are strongly encouraged for applicants to this category.

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