Holtsville Fire Department

1025 Waverly Ave Holtsville,NY 11742 (631) 475-5238

TODD METRO

Chief

RICH CAFERELLI

1st Assistant Chief

JOE EVOLA

2nd Assistant Chief

 Dear Applicant,

Thank you for showing interest in joining the Holtsville Fire Department. Volunteering your time in your community has many self-fulfilling rewards.  Attached you will find a membership application package for you to complete.

Please follow these important directions on completing your application package:

• All Captions must be completed on the application for membership booklet.
• If applicant is under 18 years of age, a parent or guardian signature is required on the application booklet. (located on the front page, bottom).
• The applicant booklet MUST be notarized before returning it to the Holtsville Fire Department.
• A $25.00 check, cash, or money order must accompany your application booklet when submitting your application to the Holtsville Fire Department.
• ALL applicants must complete and sign the criminal/arson background investigation release form attached.  This form must also be notatized.
• A copy of your drivers license must be provided.        

Each of the above listed directions is an important step in completing the application for membership booklet.  It is imperative that all of the above listed directions are completed prior to submitting your application booklet.

A member of our investigating committe will contact you shortly to complete the application process and set up an interview.  Once again thank you for your interest in joining the Holtsville Fire Department.

Firematically,

The Investigating Committee

Holtsville Fire Department

Established 1929-Reorganized 1972

HOLTSVILLE FIRE DEPARTMENT APPLICATION FOR MEMBERSHIP

Date:__________________       FIRE/AMBULANCE/FIRE & AMBULANCE (circle one)

Name of Applicant:_______________________ Date of Birth:_____________ Age:________

Residence:____________________________________ Telephone #:___________________

Place of Birth:_________________________________ SS#:__________________________

Marital Status:__________________ Length of Residence in Fire District:_________________

Highest Level of Education Completed:_____________ Where Attended:__________________

Employer:_________________ Occupation:________________ Telephone #:______________

Nearest Relative Not Living With You (Name, Address, & Telephone #): ____________________

___________________________________________________________________________

Have you previously been a member of a Fire Department:   YES    NO   If so, Which one?_________

What was the date your membership ended:___________________________________________

Please list any prior firematic or ambulance training:_____________________________________

Are you a citizen of the United States:  YES   NO           Do you speak English fluently:   YES    NO

Have you ever been arrested:   YES   NO  If so, give charge, place, date, and other pertinent details:

______________________________________________________________________________

Have you ever been convicted of a crime:   YES   NO  If so, give charge, place, date, and other pertinent details:_________________________________________________________________________

Physical Condition:_____________ Height:_________ Weight:_______ Hair Color:______________

Eye Color:_____________  Identification marks: moles, scars, tattoos:__________________________

Motor Vehicle License Number, State, Class, & Expiration Date:________________________________

ANY FALSE STATEMENT WILL BE GROUNDS FOR REJECTION OF APPLICATION OR DISMISSAL FROM MEMBERSHIP.  I DECLARE THE ABOVE ANSWERS TO BE TRUE AND CORRECT.

Signature of Applicant:_______________________________________________

If under 18, signature of parent or guardian:________________________________

Witness:___________________________________

CONSENT FORM

I, __________________________________, have this____________ day __________________, 20______, applied to become a member of the Holtsville Fire Department.

If I am approved for membership, I hereby consent to the following:

 That the Holtsville Fire Department (HFD) and/or the Board for Fire Commissioners (BOARD) receive an arrest and conviction record from any agency in the State of New York regarding the undersigned.

My correct full name is ______________________ My date of birth is ________________________

I consent to/refuse (circle one) a series of Hepatitis B Vaccines, which will be offered to me at no charge by the Board.

I am willing to accept a full physical and drug test screening prior to being accepted for membership.  I understand that if I fail the drug screening my application will be denied and my fee will be returned.

I am signing this document aware that the Board and HFD will rely on the statements made herein before approving/disapproving my membership to the HFD.

Signature of Applicant:_________________________________________

Sworn To Me Before This Date:__________________________________

__________________________

Public Notary

This application should be presented first to the unit (fire or ambulance) for which the applicant whishes to join, it will then be referred to the Invesigation Committee, who will fill in the report below.

REPORT OF THE INVESTIGATING COMMITTEE

We, the indersigned members of the Investigating Committee, have interviewed the within-named applicant and found him/her to be of good moral character and physically fit.  We recommend that this application be approved and the applicant be accepted for membership after having a prior instruction and medical examination by the District Physician.

Investigation Committee:________________,___________________,________________

If not recommended for membership:___________________________________________

_______________________________________________________________________

The Chairman of the Board of the Fire Commissioners of the Holtsville Fire District, at a regular meeting of the board, has sworn in the above applicant.

Date:_______________ Chairman, Board of Fire Commissioners:____________________

The applicant having met all rules and regulations of the Fire Department and board of Fire Commissioners, this application is finally approved and he/she is declared a member of the company designated herein.

Date:_____________________  Chief, Holtsville Fire Department:____________________________

Holtsville Fire Department

1025 Waverly Ave Holtsville, NY 11742 (631) 475-5238

TODD METRO

Chief

RICH CAFERELLI

1st Assistant Chief

JOE EVOLA

2nd Assistant Chief

Date:____________________________

Suffolk County Police Department

Yaphank Ave.

Yaphank, New York 11980

To Whom It May Concern:

I hereby authorize the Suffolk County Police Department to perform an arson, a license, and criminal background check, including sealed records (if any), on myself.  I also am authorizing the release of this information to go directly to the Chief of the above-named Fire Department.

                         Name:____________________________________________________

                        Address:__________________________________________________

                         D.O.B:____________________________________________________

                        Social Security:______________________________________________

Sworn To Me Before This Date: ______________________________________

________________________

Pubilc Notary

Sincerely,

Chief of the Department

Established 1929- Reorganized 1972