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2. 
3. Colchester Fire Department Volunteer Membership Application
5. GENERAL INFORMATION
7. Position for which you are applying*

   1. ​Junior Member (Ages 14-17)
   2. Member (Age 18+)
9. How did you learn of this opportunity?*
11. PERSONAL INFORMATION
13. Last Name*
14. First Name*
15. Middle Initial
17. Street Address*
18. City*
19. State*
21. Zip Code*
22. Mailing Address

    If different from street address.

24. Phone Number*
25. Email Address*
27. Have you applied with the Town of Colchester previously?*

    1. Yes
    2. No
28. If yes, when?
30. Do you have a valid driver's license?*

    1. Yes
    2. No
31. CDL endorsement (not required)?

    1. Yes
    2. No
33. Are you a U.S. Citizen?*

    1. Yes
    2. No
35. If not, can you submit proof that you are authorized to work in the U.S. under Federal Law? (If hired, you must furnish valid documentation that you are legally entitled to work in the U.S.)
37. Successful applicants for the position of Member (Age 18+) will be required to consent to a criminal background check.
39. Education
41. High School Diploma/GED? If not, highest grade completed?*
    -- Select One --91011HS/GED
43. College/University/Technical College?
44. Degree/Certificate Earned?
46. Other professional training or certifications that would be an asset to the Colchester Fire Department?
48. EMPLOYMENT HISTORY

    Begin with most recent. If unemployed, write N/A.

50. Employer*
51. Dates of Employment
53. Address
54. Phone
56. Last Position Held
57. Supervisor
59. Responsibilities
61. Reason for Leaving
63. Job Title and Responsibilities
65. Employer
66. Dates of Employment
68. Address
69. Phone
71. Last Position Held
72. Supervisor
74. Responsibilities
76. Reason for Leaving
78. Employer
79. Dates of Employment
81. Address
82. Phone
84. Last Position Held
85. Supervisor
87. Responsibilities
89. Reason for Leaving
91. MILITARY SERVICE
93. Branch
94. Dates of Service
96. Discharge Status
97. Rank at Discharge
99. CURRENT/FORMER MEMBERSHIP IN OTHER ORGANIZATIONS
101. Organization
102. Dates of Membership
104. Position
105. Contact
107. Organization
108. Dates of Membership
110. Position
111. Contact
113. Organization
114. Dates of Membership
116. Position
117. Contact
119. REFERENCES

     Please provide three professional or academic references:

121. Name*
122. Address
123. Phone
124. Email
126. Name*
127. Address
128. Phone
129. Email
131. Name*
132. Address
133. Phone
134. Email
136. AVAILABILITY
138. You will be required to attend regular weekly trainings (approximately 7:00PM-9:00PM). Are you able to meet this requirement?*

     1. Yes
     2. No
140. Please select your availability for the following days and time ranges (select all that apply):*

     1. Weekdays
     2. Weeknights
     3. Weekends
142. In order to be available for emergency calls, you must be able to arrive at the fire station promptly and have abstained from any alcohol or drug use for the previous twelve (12) hours.
144. ABILITY TO PERFORM ESSENTIAL FUNCTIONS
146. The law requires Firefighters to be physically capable of performing emergency duties, including, but not limited to, heavy lifting, climbing, pushing, pulling and working in extreme temperatures. Do you have any physical limitations that would restrict your ability to perform those duties?
148. STATEMENT OF AFFIRMATION

     I hereby affirm that the information I have provided on this application is true and accurate to the best of my knowledge. I authorize the verification of any or all of the information I have provided and any inquiries permissible by law to determine my suitability for membership. I understand that omissions or misrepresentations may be cause for rejection or, if I am accepted, may be just cause for immediate dismissal.

150. Applicant Signature*
151. Print
152. Date

154. The Town of Colchester is an Equal Opportunity Employer. It is the policy of the Town to provide equal employment opportunity to all applicants and employees without regard to race, color, religion, gender or sexual orientation, age, or any other status protected by state or Federal Law.

156. PARENTAL CONSENT (APPLICANTS FOR JUNIOR MEMBERSHIP, AGE 14-17)
158. Name
159. has my permission to be a Junior Firefighter with the Town of Colchester Fire Department; I will not hold the Town of Colchester Fire Department liable for any actions caused by my son/daughter that is not under the direction of an Officer.
161. Applicant Signature
162. Print
163. Date
165. Parent/Guardian Signature
166. Print
167. Date
169. Phone
170. Email
172. If applicable, please attach current certification cards.

     One upload per field.

173. Upload Certification

     One upload per field.

174. Upload Certification

     One upload per field.

176. Optional: Attach Resume

     One upload per field.

Leave This Blank:


178. 1. Receive an email copy of this form.
179. Email address

     This field is not part of the form submission.

180. Submit Submit and Print

* indicates a required field