Full Name: *

Home Phone: *

Work Phone:

Cell Phone:

E-Mail address: *

Mailing Address: *

Complete Civic Address: if different than mailing address *

Date of Birth ... *

Marital Status: Select one Single Married Divorced Common Law Widowed *

Who is your Beneficiary?

Beneficiary relationship to you?

Do you have any Disabilities? Yes No *

If YES please explain:

Memebership Type Requested; please select one Firefighter Medical Member Mutual Aid Member *

Previous Firefighter Experience? Yes No *

If YES please explain:

Will you submit to a medical examination, if required? Yes No *

Do you have a valid Drivers License? Yes No *

If YES what class license?

Do you have Air Brake Endorsement? Yes No

Your Occupation: *

Employer Name: *

Employer Complete Address *

Is you Employer Aware of this Application? Yes No *

Are you required to be away from the village when at work? Yes No *

Can you leave work when an alarm sounds for...? Maj. Emerg: Minor Emerg: Medical Emerg: Other: *

Please Read the following very carefully.

By clicking yes below

you are agreeing to the terms & conditions stated below.

I agree that during my one year trial period with Brooklyn Volunteer Fire Department that I will abide by all regulations and by-laws outlined by the department and also outlined in my entrance interview.

As a recruit member I will attend no less than fifty percent of all training sessions, meetings, and department functions; and a minimum of twenty percent of emergencies and do my best to meet the membership requirements to enter the department as a full time member.

I also agree that with my submission of my application for membership to the department I will be required to provide an RCMP Criminal Record check at the interview.

I also agree that if accepted by the membership as a full time member of the department at the end of my one-year trial period I will continue to abide by the same regulations stipulated above.

I also realize that during my one-year trial period, I may be released from the department at any time pending a majority vote by the membership of the Brooklyn Volunteer Fire Department.

YES - I Agree To the terms & conditions above No - I do not agree to the terms and conditions *