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Depauville Volunteer Fire Department, Inc. 
Post Office Box 99 Depauville, NY 13632-0099 Serving Since 1932
Application for Membership
Date:________________________________________________
1. Last Name_______________________ First Name _______________________ MI______
1a. List any nicknames__________________________________________________________
2. Address___________________________________________________ Apt/Suite No.____
City/Town/Village____________________________________ State________ Zip__________
3. Telephone: Home (_____) ______________ Work (_____) _______
4. How long have you lived at the above address? Years:_____ Months:_____
5. How long have you lived in New York state? Years:_____ Months:_____
6. Are you 18 years of age or older? Yes_____ No_____ If NO, state your age:_____
7. Is additional information about a change in your name or your use of an assumed name or nickname necessary to enable a check on your
eligibility for membership? Yes_____ No_____
If YES, explain:
_____________________________________________________________________
_____________________________________________________________________
8. Are you currently employed? Yes_____ No_____
If YES, give employer information below. May we contact your employer as a reference?
Yes_____ No_____
Name of Company____________________________________________________________
Address____________________________________________ Telephone_______________
9. Do you have a valid New York State Drivers License? Yes_____ No_____
10. Please indicate your availability to participate in normally required fire department activities (meetings, drills, and
emergency calls). Check the appropriate time periods:
Weekdays Days_____ Evenings_____ Nights_____
Weekends Days_____ Evenings_____ Nights_____
11. Previous emergency services experience: (include only fire, rescue, police, and emergency medical service agencies)
Name of Agency _________________________________________________________
Address________________________________________________________________
Contact Person____________________________________Telephone______________
If you need more space, please identify in the space provided on page 3 of the form.
12. Have you ever been a member of the United States Armed Forces? Yes_____ No_____
If the answer is YES, did you receive an Honorable Discharge? Yes_____ No_____
If the above answer is YES, give complete details in the space provided on the form. Include service branch and dates of service.
Other than honorable discharge is not an absolute bar to membership. This and other factors will effect a final membership decision.
13. Have youe ever been convicted or pled guilty to a felony, misdemeanor, insurance fraud, arson, or a reduction of
one of these charges? Yes_____ No_____
If YES give details in the space provided on the form.
14. Please list three personal references, other than members of this organization or blood relatives, who have known you for
at least three (3) years.
A. Name________________________________________ Telephone___________________
Address_____________________________________________________________________
B. Name________________________________________ Telephone___________________
Address_____________________________________________________________________
C. Name________________________________________ Telephone___________________
Address_____________________________________________________________________
15. Please list the names of any acquaintances that are members of this organization:
___________________________________________________________________________
___________________________________________________________________________
16. OSHA regulations require that you pass a physical examination before becoming an interior structural
firefighter. The department's designated physician will provide you with a free medical examination. Will you be
willing to undergo a medical examination? Yes_____ No_____
ADDITIONAL INFORMATION
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Item_____ ______________________________________________________________
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Item_____ ______________________________________________________________
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Item_____ ______________________________________________________________
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If you need additional space use blank paper.
The following information will be used in processing your application:
This includes a state mandated check for arson convictions.
Date of Birth: ___________________ Height _______ Weight _______
Place of Birth: ____________________________________________
Race: ____________ q I decline to provide this information.
The following information is needed for Fire Department records:
Drivers License Number ___________________ State_____
Social Security Number___________________
Within the Freedom of Information Law, all information contained or obtained herein will remain
confidential and will be used only for membership processing.
In witness whereof, this applicant has subscribed this ______ day of ____________, 20___ by the undersigned
applicant who affirms that that the statements made herein are true under the penalties of perjury.
Applicant Signature____________________________________________________________
Date__________________________________
Witnessed By_________________________________________________________________
Date__________________________________
Privacy Notification
Section 94 of the public officers law (Personal Privacy Protection Law) requires that you be notified of the following facts
when information which will be maintained in a record system is collected from you.
The authority to request and confirm personal information about you is found in Article 6 of the Executive Law.
The information obtained will:
m be used to determine your qualifications for the position
for which you are applying;
m be released to the Fire Chief and your potential supervisors; and
m be maintained in your personnel file (if you become a
fire company member) or in our resume file for six months (if you are not a fire company member).
Failure to provide the information or authorization will result in your application not being considered for membership.