Application For Membership - City Of Cuba Fire Department
ADVERTISEMENT
1For CFD Board & Department Use
Cuba Fire Department
Application Received: _________
Board Interview time: _________
51 E. Main Street
Request for Interview sent: ______
PO Box 84
Arson Report to Sheriff: _________
Cuba, NY 14727
Arson Report from Sheriff: _______
585-968-2530
Physical Request to County: ______
Membership Vote: ______
Cast ____ In____ Out____
Application for Membership
I respectfully submit this application to become a member of the Cuba Fire Department.
Name ___________________________________ Phone (Cell) (_____) __________________
Last, First
Phone (Home)(_____) _________________
Email ___________________________________ Phone (Work)(_____)__________________
Address:______________________________________________________________________
City: ____________________________________Zip ________________________________
Soc Sec#: _______________________________ Date of Birth: ____/____/_____ Sex: M F
Employer: __________________________________
Work Hours:____________________
Drivers Lic#: _________________________________ License Class:___________________
Have you belonged to another fire department? Yes No If yes, list all previous departments
and reasons for leaving. Please continue on reverse if necessary.
Dept Name: _______________________
Reason for Leaving:___________________
Dept Name: _______________________
Reason for Leaving: ___________________
As added protection for you and your fellow fire fighters, we request that you answer the
following questions. Do you have any problems or limitations with any of the following?
Vision: Y or N
Hearing: Y or N Sense of Smell: Y or N
Hernia: Y or N
Back: Y or N
Knees: Y or N
Cardiac: Y or N
Blood Pressure: Y or N
Arms: Y or N
Hands: Y or N
Shoulder: Y or N
Feet: Y or N
Lungs/Breathing: Y or N
Other Problems:______________
Y or N Have you ever had any previous injuries incurred in relation to an auto, work, or sport
accident/incident?
Y or N Do you have any other limitations which might affect your ability to serve as an active
volunteer fire fighter?
If you answered yes to any of the above items, please describe and give the date of all injuries
or illnesses. Please continue on reverse if necessary. _________________________________
I have read the Constitution and By-Laws and Standard Operating Procedures of the Cuba Fire
Department and have read the Rules and Regulations and Policies of the Cuba Joint Fire
District and understand their provisions. I agree to abide by these to the best of my ability. I also
understand that all applications must be interviewed by the Board of Directors and failure to
appear for this interview will void this application.
Signature __________________________
I certify the above information to be correct.
Signature__________________________Date_______________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal