New Member Application v2 - Somers Volunteer Fire Department, Inc.

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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

â€¹ â€º Ã—

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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www.FirehouseSolutions.com	Somers VFD IT Committee Post Office Box 272 Somers, New York 10589	Emergency Dial 911 Non-Emergency: 914-248-5604 E-mail: webmaster@somersvfd.com