Rutland Town Fire Membership Membership Information for the Rutland Town Fire Department Please complete this form if you are interested in joining our Fire Department. Once completed, the form will be forwarded to a Chief Officer for follow up. Step 1 of 4 25% Your Personal InformationDate(Required) MM slash DD slash YYYY Your Name(Required) First Last Your Email Address Enter Email Confirm Email Address(Required)We are able to consider applicants who currently live in the Town of Rutland, the City of Rutland, or the Town of Mendon. Physical Address Line 1 Physical Address Line 2 City State / Province / Region ZIP / Postal Code Do you have a different mailing address? Yes No AddressWe are able to consider applicants who currently live in the Town of Rutland, the City of Rutland, or the Town of Mendon. Mailing Address Line 1 Mailing Address Line 2 City State / Province / Region ZIP / Postal Code Cell Phone NumberHome Phone NumberBest Time To Call YouWhen is the best time for us to reach you via telephone?MorningsEarly AfternoonLate AfternoonEarly EveningAnytimeDo you have a valid driver's license?(Required) Yes No Membership Type(Required) Senior Firefighter (18+) Junior Firefighter (16 – 18) Cadet Firefighter (14 – 16) Senior Firefighter (18+)(Required) Yes No Are you an active or past military member? Yes No Branch ServedDate From(Required)Date your service began MM slash DD slash YYYY Date ToIf still active leave blank MM slash DD slash YYYY Relevant military training or experience Employment HistoryAre you currently employed?(Required) Yes No Current EmployerPlease list your employer information.EmployerSupervisorPositionPhone Add RemoveIs it ok to contact this employer? Yes No Please explain.Previous EmployerPlease list your previous employers, the dates you worked and the position you heldEmployerDatesPositionPhone Add RemoveIs it ok to contact this employer? Yes No Please explain.Previous EmployerPlease list your previous employers, the dates you worked and the position you heldEmployerDatesPositionPhone Add RemoveIs it ok to contact this employer? Yes No Please explain. Fire Service Training and ParticipationPrevious Fire / EMS organizations you have been affiliated withDepartment NameLocationDate JoinedDate LeftChief NameChief Phone Number Add RemoveList all certifications held. Course name, location, date completedCourse NameLocationDate Completed Add RemoveWhen are you available for calls, trainings and meetings? Weekdays Weeknights Weekends Select AllWhy do you want to join the Rutland Town Fire DepartmentMedical InformationRutland Town firefighters must be able to perform the essential functions of the firefighter role, with or without a reasonable accommodation which does not cause an undue hardship for the Department. Are you able to perform the essential functions of this role, with or without a reasonable accommodation? Yes No ReferencesPlease provide three references (not related to you) including name, occupation, and contact information (phone or email).Reference #1NameOccupationPhoneEmail Add RemoveReference #2NameOccupationPhoneEmail Add RemoveReference #3NameOccupationPhoneEmail Add RemoveDo you have a close relative currently serving in the Rutland Town Fire Department? (A close relative includes a spouse, civil union partner, romantic co-habitant, parent, stepparent, grandparent, child, stepchild, grandchild, sibling, aunt or uncle, niece or nephew, parent-in-law or sibling-in-law.) Yes No Who is the member? Electronic Signature AgreementBy electronically signing below you agree and acknowledge that: 1. You authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature. 2. You may still be required to provide a traditional signature at a later date. 3. The information provided is true and accurate to the best of your knowledge. 4. You authorized the verification of any or all of the information and any inquiries permissible by law to determine suitability for membership. Any intentional misrepresentation may lead to denial of membership. 5. This application is valid for 90 days.Certificate of Truthfulness(Required) I certify this is accurate I certify the information I have provided on this application is true and accurate to the best of my knowledge. I understand omissions or misrepresentations may be cause for rejection and/or removal as a member of the Rutland Town Fire Department. I understand membership may be subject to a background investigation and a 6-month probationary period per the Standard Operating Guidelines.(Required)Electronic SignatureUpload certification documentUpload your document in .pdf, .doc or .docx formatAccepted file types: pdf, doc, docx, Max. file size: 25 MB. Upload certification documentUpload your document in .pdf, .doc or .docx formatAccepted file types: pdf, doc, docx, Max. file size: 25 MB. Upload Your ResumeUpload your document in .pdf, .doc or .docx formatAccepted file types: pdf, doc, docx, Max. file size: 25 MB. 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