Application For Membership - Bellmawr Fire Department (Page 7 of 7) in pdf

AFFIDAVIT

I certify that all information provided in this membership application is true and complete. I understand that any

false information or omission may disqualify me from further consideration for membership and may result in my

dismissal if discovered at a later date.

I understand that the Bellmawr Fire Department may request an investigative consumer report from a consumer

reporting agency. This report may include information as to my character, reputation, personal characteristics and

mode of living obtained from interviews with neighbors, friends, former employers, schools, and others. I

understand I have the right to make a written request within a reasonable time for disclosure of the nature and

scope of the investigation.

I authorize the investigation of any or all statements contained in this application and also authorize any person,

school, current employers (except as previously noted), past employers, and organizations names in this

application to provide relevant information and opinions that may be useful in making a membership decision. I

release such persons and organizations from any legal liability in making such statements.

I understand that if I am extended an offer of membership, it may be conditioned upon my successfully passing a

complete pre-employment physical examination. I consent to the release of any or all medical information as may

be deemed necessary to judge my capacity to do the work for which I am applying.

I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre

and/or post employment drug screen as a condition of employment, if required.

I UNDERSTAND THAT THIS APPLICATION FOR SUBSEQUENT MEMBERSHIP DOES NOT CREATE AN

EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE MEMBERSHIP FOR ANY

DEFINITE PERIOD OF TIME.

I have read, understand, and by my signature, consent to these statements.

Signature: ___________________________________Date: __________________________________

STATE OF NEW JERSEY, COUNTY OF ________________ being duly sworn, doth depose and says that the

above statements are true to the best of their knowledge and belief.

Sworn to before me this ____________________ day of _____________________ 20_______.

________________________________

Signature of NOTARY PUBLIC

Application For Membership - Bellmawr Fire Department Page 7