Membership Application | Sea Bright Fire Rescue

Application for Membership

Form 100-03 · Please type or print. Fields marked * are required.

Membership type

Full Time Membership

Seasonal Membership (May 1 through September 30)

Personal information

Last name*

Suffix

M.I.

First name*

Email address*

Home address*

City*

State*

Zip*

Cell phone*

Mobile carrier

Driver's license number

License state

Social security number

Sent securely and visible only to department administrators.

Current affiliation

Current active fire department

Chief / point of contact

Contact phone

Fire / medical service training

List courses completed and the date each was completed.

Course

Completion date

Course

Completion date

NJDFS ID #

NJDOH EMT #

Background & disclosures

Have you ever been suspended or removed from a prior emergency services organization?

Yes

Have you ever been convicted of a crime or offense?

Yes

Have you ever been a defendant or plaintiff of a domestic violence incident?

Yes

Certification & release

I certify that the statements made within this application are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I am aware that any misrepresentation of information supplied by me will result in my disqualification from the selection process. Furthermore, I authorize the Sea Bright Police Department to verify any and all information contained herein and to review my employment, education and criminal history, disciplinary records, and any other records and information from any source as noted in the duly executed Authority and Release form. I have read this Certification and I understand and agree to the conditions imposed herein.

I have read this certification and I understand and agree to the conditions imposed herein.

Signature of applicant

Sign here

Typed legal signature

Applicant name (print)*

Date*