Membership Application

UJFD Membership Application

Personal Information

First name

Middle Initial

Last name

Street Address

City

Region/State/Province

Postal / Zip code

Date of Birth

Drivers License Number

Phone

State Issued

License Expiration Date

Current Employer

Employer Phone

Employer Street Address

EmployerCity

Empoloyer Region/State/Province

Employer Postal / Zip code

Emergency Contact

Emergency Contact first name

Emergency Contact last name

Emergency Contact Street Address

Emergency Contact City

Emergency Contact Region/State/Province

Emergency Contact Postal / Zip code

Emergency Contact Phone

Emergency Contact Alternate Phone

Applicant Questions

If Yes, please describe your experience and where

If YES, When ?

Vermont EMS License Number

National Registry Number

Reference Section

Note: For applicants with 6 or more months or continuous service in the last two years on either an EMS agency or Fire Department, Please make sure one of your references is from the head of that service.

Please List 3 Non-family References Below

Reference 1 - Name

Reference 1 - Relationship

Reference 1 - Phone

Reference 2 - Name

Reference 2 - Relationship

Reference 2 - Phone

Reference 3 - Name

Reference 3 - Relationship

Reference 3 - Phone

Requirements for All Members

• All applicants, except when applying solely for the position of specialist, will be required to successfully complete an apprenticeship program as stated in the Department Bylaws. This apprenticeship period will last for approximately one year.

• All applicants will be required to complete the National Incident Management System (NIMS) certification process for levels 100, 200 and 700 through a free online course prior to starting the apprenticeship period.

• All applicants must complete and pass a medical exam from a UJFD designated physician, at the expense of the fire department, prior to gear and equipment being issued or being allowed to respond to emergency calls.

ADDITIONAL REQUIREMENTS OF FIREFIGHTER APPLICANTS
• Firefighter applicants must complete, or show proof of completion, the Chittenden County Basic Firefighting Course or Vermont State Firefighter Level 1 course within two years of their start date.

• Applicants under the age of eighteen (18) years of age must have approval from a parent or legal guardian.

ADDITIONAL REQUIREMENTS OF EMS FIRST RESPONDER APPLICANTS
• EMS First Responder applicants will be required to complete National Incident Management (NIMS) level 800 certification through a free online course prior to starting the apprenticeship period.

• EMS First Responder applicants must complete and obtain, or show proof of a Vermont issued EMR, EMT or AEMT License and National Registry Card prior to starting the apprenticeship period.

• Applicants must be (18) years of age or older to join as an EMS First Responder.

I attest the information in this application for membership in the Underhill-Jericho Fire Department Inc. is true, complete and factual. I understand that if I am accepted, any false statements or intentional misrepresentation in this application shall be considered sufficient cause for dismissal.

I hereby authorize the Underhill-Jericho Fire Department, Inc. to conduct an investigation of my personal history, including but not limited to: a DMV driver check, criminal background check, sex offender registry check, adult and child abuse registry check, and Office of Inspector General exclusion list check, etc.

By signing this application, if accepted as a member of the UJFD, I agree to follow all applicable Federal laws, State laws and Department rules (bylaws, policies and guidelines). I hereby further certify that I am not under any obligation to pay child support or I am in good standing as defined in 15 V.S.A. Section 795, regarding child support. I hereby further certify that I am in good standing as defined in 32 V.S.A. Section 3113, with respect to, or in full compliance with a plan to pay, any and all taxes due as of this date.

Your Signature

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