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August 9, 2012
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May 20, 2022
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New Member Application v2
Indicates Required Field
Membership type:
EMS
Fire & EMS
First Name:
Last Name:
HOME ADDRESS
Street:
City:
State:
Zip Code:
MAILING ADDRESS (if different from home)
Street2:
City2:
State2:
Zip Code2:
PERSONAL INFORMATION
Are you 18 or older:
Yes
No
Date of birth:
Social Security Number:
Are you a citizen of the USA:
Yes
No
Email Address:
Landline:
Cell Phone:
Are you now or have you been a member of another fire department:
Yes
No
NYS training ID:
If a prior member of another department
FEMA ID:
If a prior member of another department
Height (inches):
Eye color:
Hair color:
EMERGENCY CONTACT INFO
Name - emergency:
Address - emergency:
Relationship - emergency:
Cellphone - emergency:
Email - emergency:
Landline - emergency:
EDUCATION
High School Name & Address:
HS Years completed:
HS Year graduated:
College/tech school name & Address:
College/tech years completed:
College/tech year graduated:
Other School name & address:
Other school years attended:
Other School year graduated:
Employment (last 5 years)
Present employer name/address/phone:
Present employer position:
Present employer start date:
Present employer supervisor name:
Previous employer name/address/phone:
Previous employer position:
Previous employer start date:
Previous employer end date:
Previous employer supervisor name:
Do you have any objection to the SVFD contacting your current employer:
Yes
No
Do you have any objection to the SVFD contacting your previous employer:
Yes
No
Military Service
Have you served in the military:
Yes
No
Branch of military:
Years of service:
Type of discharge:
Honorable
Dishonorable
Prior volunteer fire department or ambulance service
Have you ever applied to any volunteer fire department or ambulance corp:
Yes
No
Which department:
Department's phone number:
Date applied:
Was your application accepted:
Yes
No
If rejected, please explain:
Have you ever been a member of a volunteer fire department or ambulance corp:
Yes
No
Department name/phone:
Member from date:
Member to date::
Chief's name and Phone:
Other
Arrested for any violation of law:
Yes
No
Arrest explanation:
Indicted for any violation of law:
Yes
No
Indicted explanation::
Convicted of any violation of law:
Yes
No
Conviction explanation:
Drivers license number:
Drivers license state::
Drivers license expiration date::
Drivers license class::
Membership in other clubs and organizations
Club/Org Name & Address 1:
Club/Org Phone 1:
Club/Org supervisor 1:
Club/org join date 1:
Club/org leave date 1 (leave blank if still a member):
Club/Org Name & Address 2:
Club/Org Phone 2:
Club/Org supervisor 2:
Club/org join date 2:
Club/org leave date 2 (leave blank if still a member):
Signatures - your initials will serve as your electronic signature
Please tell us why you want to join the Somers Volunteer Fire Department:
I acknowledge and understand that:
Yes
I declare that:
Yes
Signature:
Parents signature:
If applicant is under 18
References
Guideline1. References may NOT include your spouse or any relative, either by blood or by marriage, husband/wife combinations, or any 2 members of the same family household.
Guideline2. References should be known to applicant for at least 3 years.
Guideline3. Members of the Somers Volunteer Fire Department may not be used as references, but may be included in the space provided.
Reference 1 name and address:
Reference 1 phone:
Reference 1 - How are you acquainted:
Reference 2 name and address:
Reference 2 phone:
Reference 2 - How are you acquainted:
Reference 3 name and address:
Reference 3 phone:
Reference 3 - How are you acquainted:
Additional references:
Timestamp:
05/20/2022 2009
‹
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×
2022 incidents
Fire
EMS
JAN
54
180
FEB
41
139
MAR
50
149
APR
52
170
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
Total
197
638
2021 Incidents
Fire
EMS
JAN
35
201
FEB
41
179
MAR
65
160
APR
42
169
MAY
52
162
JUN
70
192
JUL
96
176
AUG
55
192
SEP
76
161
OCT
54
172
NOV
49
167
DEC
57
220
Total
692
2151
2020 Incidents
Fire
EMS
JAN
44
167
FEB
51
148
MAR
40
159
APR
58
162
MAY
48
140
JUN
64
133
JUL
56
168
AUG
173
169
SEP
60
140
OCT
45
162
NOV
54
134
DEC
62
179
Total
755
1861
2019 Incidents
Month
Fire
EMS
Jan
47
172
Feb
48
150
Mar
48
177
Apr
43
173
May
41
183
Jun
49
158
Jul
64
153
Aug
43
152
Sep
42
175
Oct
50
145
Nov
53
136
Dec
48
221
Total
576
1995
2018 Incidents
Fire
EMS
Jan
58
152
Feb
47
153
Mar
177
178
Apr
38
143
May
71
174
Jun
59
172
Jul
62
159
Aug
68
177
Sep
39
178
Oct
52
160
Nov
46
172
Dec
49
169
Total
766
1987
2017 Incidents
Fire
EMS
Jan
44
152
Feb
40
140
Mar
39
138
Apr
50
151
May
49
144
Jun
53
119
Jul
62
131
Aug
50
129
Sep
49
158
Oct
57
137
Nov
58
159
Dec
47
178
Total
598
1736
2016 Incidents
Fire
EMS
Jan
53
118
Feb
64
126
Mar
30
146
Apr
45
120
May
50
112
Jun
54
142
Jul
49
132
Aug
60
137
Sep
37
160
Oct
55
161
Nov
47
131
Dec
38
154
Total
582
1639
2015 Incidents
Fire
EMS
Jan
39
136
Feb
52
149
Mar
50
160
Apr
40
100
May
59
145
Jun
45
116
Jul
57
166
Aug
39
140
Sep
34
151
Oct
44
140
Nov
30
125
Dec
53
160
Total
542
1688
2014 Incidents
Fire
EMS
Jan
40
124
Feb
32
121
Mar
40
110
Apr
39
118
May
46
155
Jun
28
147
Jul
54
146
Aug
44
136
Sep
47
139
Oct
48
135
Nov
56
108
Dec
45
143
Total
519
1582
Older Incidents
Fire
EMS
2013
472
1588
2012
628
1613
2011
708
1654
2010
525
1562
2009
468
1474
2008
493
1385
2007
519
1339
2006
478
1195
2005
569
1160
2004
533
979
2003
730
706
2002
959
397
Total
7082
15052
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