Waterford Fire Department Membership Application (PDF)

Membership Application
Waterford Fire Department
Application date
General Information
Name sex
Address
Home Phone Cell Phone
Email
SS # Date of Birth
Drivers Lic. # Class State Expires
Emergency Contact
Name Relation
Home Phone Other Phone
Address
Other Information
Employer
Address Phone
Name and address of two people who are not firefighters and not related to you and have known you
for at least five years
Name Address Phone
Name Address Phone
Have you ever been convicted of a felony? Yes No

Education/Certifications
High School Address Graduated Y/N Graduation Date
College Address Graduated Y/N Graduation Date
Technical School Address Graduated Y/N Graduation Date
List any fire, rescue, or medical related certifications you hold and their expirations dates (attach copies)
Certification _ Expiration
Miscellaneous
Would you be able to respond to calls:
During the night During working hours Overnight
Do you have any other response commitments that might keep you from responding Yes _—§ No___
Explain
Do you understand calls may come at various times of the day or night Yes No
Please address any concerns you may have
| certify that the information given herein is true and complete to the best of my knowledge.
Signature

DISCLOSURE FOR CONSUMER REPORT
Town of Waterford (“the Company”) may obtain information about you from a third- party
consumer reporting agency for employment purposes (including independent contractor or
volunteer assignments, as applicable). Thus, you may be the subject of a “consumer report”
which may include information about your character, general reputation, personal
characteristics, and/or mode of living. These reports may contain information regarding your
criminal history, public court records, Social Security verification and address history, motor
vehicle records (“driving records”), drug/alcohol test results, verification of your education or
employment history, or other background checks, subject to any limitations imposed by
applicable federal and state law.
You have the right, upon written request made within a reasonable time, to request whether a
consumer report has been run about you and to request a copy of your report. These searches
will be conducted by Foley Carrier Services, LLC (“Agency”), 2 Huntington Quadrangle, South
Building, Second Floor, Suite 2S04, Melville, NY 11747, telephone
number (631) 557-0100, www.foleyservices.com .
(Cl tHave Read and Understand the FCRA Disclosure for Consumer Report
Print Name:
Signature:
Date:
7/24/2019

DISCLOSURE FOR INVESTIGATIVE CONSUMER REPORT
Town of Waterford (“the Company”) may request an investigative consumer report
about you froma third-party consumer reporting agency, in connection with your
employment or application for employment (including independent contractor or
volunteer assignments, as applicable). An “investigative consumer report” is a background
report that includes information from personal interviews (except in California, where that
term includes background reports with or without information obtained from personal .
interviews). The most common form of an investigative consumer report in connection
with your employment is a reference check through personal interviews with sources such
as your former employers and associates, and other information sources. The investigative
consumer report may contain information concerning your character, general reputation,
personal characteristics, or mode of living. You may request more information about the
nature and scope of an investigative consumer report, if any, by contacting the Company.
These searches will be conducted by Foley Carrier Services, LLC (“Agency”), 2 Huntington
Quadrangle, South Building, Second Floor, Suite 2504, Melville, NY 11747, telephone number
(631) 557-0100, www.foleyservices.com.
Print Name: ' Date:
Signature:
SSN: DOB:
Phone: Email:
7/24/2019

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4 « 3
ACKNOWLEDGEMENT AND AUTHORIZATION FOR BACKGROUND CHECK
| acknowledge receipt of the separate documents entitled DISCLOSURE OF CONSUMER AND/OR
INVESTIGATIVE CONSUMER REPORT and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT
REPORTING ACT and certify that | have read and understand each of those documents.
| hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by
Town of Waterfor d (the “Company”) at any time after receipt of this authorization and throughout
my employment, (including independent contractor or volunteer assignments, as applicable). To this end,
{hereby authorize any law enforcement agency, administrator, state or federal agency, institution,
school or university (public or private), information service bureau, employer, or insurance company
to furnish any and all background information requested by Foley Carrier Services, LLC (“Agency”), 2
Huntington Quadrangle, South Building, Second Floor, Suite 2804, Melville, NY 11747, telephone
number
(631) 557-0100, www.foleyservices.com . | understand that there may be an overseas transfer of
my information. | consent to and authorize the processing of my information in a foreign country by
a third-party providing services to the Company and understand that this information may be
accessible to law enforcement and national security authorities of that jurisdiction. | agree that a
facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the
original.
New York applicants/employees: Upon request, you will be informed whether or not a consumer report was
requested by the Company, and if such report was requested, informed of the name and address of the consumer
reporting ,
agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer
report requested by the Company by contacting the consumer reporting agency identified above directly. By signing
below, you acknowledge receipt of Article 23-A of the New York Correction Law.
New York City applicants/employees: You acknowledge and authorize the Company to provide any notices
required
py federal, state or local law to you at the address(es) and/or email address(es) you provided to the company.
Washington State applicants/employees: You also have the right to request from the consumer reporting agency a
written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
- Minnesota and Oklahoma applicants/employees: Please check this box if you would like to receive a free copy of a
consumer report if one is obtained by the Company.
C1! Have Read and Understand the Acknowledgement & Authorization for Background Check |
Print Name: Date:
Address: City State:
Previous Address: City: State:
Signature:
7/24/2019

AGREE TO RECEIVE NOTIFICATIONS ELECTRONICALLY
You hereby agree to receive and respond electronically to all Communications for those products and
services offered or accessible through Foley Carrier Services’ website that are not otherwise governed
by the terms and conditions of an electronic disclosure and consent.
4. Definitions The words "we," "us," and “our" refer to the entity that will be performing the
background check, and the words "you" and "your" mean you, the subject of the background
- check. "Communication" means any disclosures, notices, outcomes, determinations, disputes
correspondence, results of reinvestigation, amended consumer reports and all other information
related to your background check, including but not limited to information that we and/or your
prospective employer are required by law to provide to you in writing.
2. Electronic Delivery of Disclosures and Notices. You hereby consent to receive any
Communications and all changes to such Communications electronically at the following email
address:
(Insert current email address)
You must provide at your own expense an Internet connected device that is compatible with the
minimum requirements outlined below. You also confirm that your device will meet these
specifications and requirements and will permit you to access and retain the Communications
electronically each time you access and use the applicable services.
Please select Print and select your printer to retain a-copy. If you do not have a printer, you can
copy the text of these Terms and paste the text into a new document in a word processor or a
text editor on your computer and save the text.
3. Paper Delivery of Disclosures and Notices You have the right to receive a paper copy of the
Communications, and any changes. To receive a paper copy, please request it in one of the
following ways: call us at (877) 702-6761 or write with your name and address to: Foley Carrier
Services, LLC, 2 Huntington Quadrangle, South Building, Second Floor, Suite 2504, Melville, NY
11747. We may charge you a reasonable service charge to mail you a paper copy of any
Communication, as allowed by law. We will either include such service charge on our fee
schedule or, if we do not, before we send you the paper copy, we will first inform you of the
service charge and provide you with the choice as to whether you stillwant us to send you a
paper copy. Please be sure to state that you are requesting a copy of the Communications
referenced above.
4. System Requirements to Access Information To receive and view an electronic copy of the
Communications, you must have the following equipment and software:
o A personal computer or other device which is capable of accessing the Internet. Your
access to this page confirms that your system/device meets these requirements.
o An Internet web browser which is capable of supporting 128-bit SSL encrypted
communications, JavaScript, and cookies. Your system or device must have 128-bit SSL
encryption software. Your access to this page confirms that your browser and encryption
software/device meet these requirements.
7/24/2019

5. System Requirements to Retain Information To retain a copy, you must either have a printer
connected to your personal computer or other device or, alternatively, the ability to save a copy
through use of a printing service or software such as Adobe Acrobat®. If you have a word
processor or text editor program on your computer, then you can also copy the text of this
Disclosure and the underlying agreements and paste the text into a new document in the word
processor or text editor and save the text.
6. Withdrawal of Electronic Acceptance of Disclosures and Notices You can also contact us in any
of the ways described in the paragraph entitled "Paper Delivery of Disclosures and Notices" to
withdraw your consent to receive any future Communications electronically, including if the
system requirements described above change and you no longer possess the required system.
If you withdraw your consent, we will terminate your use of the Foley Carrier Services website
and the services provided through the Foley Carrier Services website.
7. Termination / Changes. We reserve the right, in our sole discretion, to discontinue the provision
of your electronic Communications, or to terminate or change the terms and conditions on which
we provide electronic Communications. We will provide you with notice of any such termination
or change as required by law.
oO | Have Read, Understand, and Agree to Receive Notifications Electronically
Print Name:
Signature:
Date:
7/24/2019

Para informacion en espaiiol, visite www.consumerfinance,gov/learnmore o escribe a la
Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and
privacy of information in the files of consumer reporting agencies. There are many types of
consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies
that sell information about check writing histories, medical records, and rental history records).
Here is asummary of your major rights under FCRA. For more information, including
information about additional rights, go to www.consumerfinance.gov/learnmore or write
to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
¢. You must be told if information in. your file has been used against you. Anyone who
uses a credit report or another type of consumer report to deny your application for credit,
insurance, or employment -— or to take another adverse action against you — must tell you,
and must give you the name, address, and phone number of the agency that provided the
information.
* You have the right to know what is in your file. You may request and obtain all the
information about you in the files of a consumer reporting agency (your “file
disclosure”). You will be required to provide proper identification, which may include
your Social Security number. In many cases, the disclosure will be free. You areentitled
to a free file disclosure if
a person has taken adverse action against you because of information in your
credit report;
you are the victim of identity theft and place a fraud alert in your file;
your file contains inaccurate information as a result of fraud;
you are on public assistance;
you are unemployed but expect to apply for employment within 60 days.
ie)
Oo 0o00
In addition, all consumers are entitled to one free disclosure every 12 months upon
request from each nationwide credit bureau and from nationwide specialty consumer
reporting agencies. See www.consumerfinance. gov/learnmore for additional
information.
¢ Yow have the right to ask for a credit score. Credit scores are numerical summaries of
your credit-worthiness based on information from credit bureaus. You may request a
credit score from consumer reporting agencies that create scores or distribute scoresused
in residential real property loans, but you will have to pay for it. In some mortgage
transactions, you will receive credit score information for free from the mortgagelender.
* You have the right to dispute incomplete or inaccurate information. If your
identify information in your file that is incomplete or inaccurate, and report it to the
consumer ;

reporting agency, the agency must investigate unless your dispute is frivolous. See
www.consumerfinance. gov/learnmore for an explanation of dispute procedures.
Consumer reporting agencies must correct or delete inaccurate, incomplete, or
unverifiable information. Inaccurate, incomplete, or unverifiable information must be
removed or corrected, usually within 30 days. However, a consumer reporting agency
may continue to report information it has verified as accurate.
Consumer reporting agencies may not report outdated negative information. In
most cases, a consumer reporting agency may not report negative information that is
more than seven years old, or bankruptcies that are more than 10 years old.
Access to your file is limited. A consumer reporting agency may provide information
about you only to people with a valid need — usually to consider an application with a
creditor, insurer, employer, landlord, or other business. The FCRA specifies those witha
valid need for access.
You must give your consent for reports to be provided to employers. A consumer
reporting agency may not give out information about you to your employer, or apotential
employer, without your written consent given to the employer. Written consent generally
is not required in the trucking industry. For more information, go to_
www.consumerfinance.gov/learnmore.
You may limit “prescreened” offers of credit and insurance you get based on
information in your credit report. Unsolicited “prescreened” offers for credit and
insurance must include a toll-free phone number you can call if you choose to remove
your name and address form the lists these offers are based on. You may opt out with the
nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).
The following FCRA right applies with respect to nationwide consumer reporting
agencies:
CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE
You have a right to place a “security freeze” on your credit report, which will
prohibit a consumer reporting agency from releasing information in your credit
report without your express authorization. The security freeze is designed to prevent
credit, loans, and services from being approved in your name without your consent.
However, you should be aware that using a security freeze to take control over who gets
access to the personal and financial information in your credit report may delay, interfere
with, or prohibit the timely approval of any subsequent request or application you make
regarding a new loan, credit, mortgage, or any other account involving the extension of
credit.
As an alternative to a security freeze, you have the right to place an initial or extended
fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is

placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s
credit file, a business is required to take steps to verify the consumer’s identity before
extending new credit. If you are a victim of identity theft, you are entitled to an extended
fraud alert, which is a fraud alert lasting 7 years.
A security freeze does not apply to a person or entity, or its affiliates, or collection
agencies acting on behalf of the person or entity, with which you have an existing
" account that requests information in your credit report for the purposes of reviewing or
collecting the account. Reviewing the account includes activities related to account
maintenance, monitoring, credit line increases, and account upgrades and enhancements.
* You may seek damages from violators. If a consumer reporting agency, or, in some
cases, a user of consumer reports or a furnisher of information to a consumer reporting
agency violates the FCRA, you may be able to sue in state or federal court.
- Identity theft victims and active duty military personnel have additional rights. For
more information, visit www.consumerfinance. gov/learnmore.
States may enforce the FCRA, and many states have their own consumer reporting laws.
In some cases, you may have more rights under state law. For more information, contact
your state or local consumer protection agency or your state Attorney General. For
information about your federal rights, contact:

TYPE OF BUSINESS: _ --
CONTACT:
1.a. Banks, savings associations, and credit unions with total
assets of over $10 billion and their affiliates
| b. Such affiliates that are not banks, savings associations, or
credit unions also should list, in addition to the CFPB:
a. Consumer Financial Protection Bureau
1700 G Street, N.W.
Washington, DC 20552
b, Federal Trade Commission
Consumer Response Center
600 Pennsylvania Avenue, N.W.
Washington, DC 20580
(877) 382-4357
2. To the extent not included in item 1 above:
a, National banks, federal savings associations, and federal
’ branches and federal agencies of foreign banks
b. State member banks, branches and agencies of foreign banks
(other than federal branches, federal agencies, and Insured State
Branches of Foreign Banks), commercial lending companies
owned or controlled by foreign banks, and organizations
operating under section 25 or 25A of the Federal Reserve Act.
c. Nonmember Insured Banks, Insured State Branches of
Foreign Banks, and insured state savings associations
d. Federal Credit Unions
a. Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
b. Federal Reserve Consumer Help Center
P.O. Box 1200
Minneapolis, MN 55480
c. FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
d. National Credit Union Administration
Office of Consumer Financial Protection (OCFP)
Division of Consumer Compliance Policy and Outreach
1775 Duke Street
Alexandria, VA 22314
3. Air carriers
Asst, General Counsel for Aviation Enforcement & Proceedings
Aviation Consumer Protection Division
Department of Transportation
1200 New Jersey Avenue, S.E.
Washington, DC 20590
4, Creditors Subject to the Surface Transportation Board
Office of Proceedings, Surface Transportation Board
Department of Transportation
395 E Street, S.-W.
Washington, DC 20423
5. Creditors Subject to the Packers and Stockyards Act, 1921
Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies
Associate Deputy Administrator for Capital Access
United States Small Business Administration
409 Third Street, 8.W., Suite 8200
Washington, DC 20416
7. Brokers and Dealers
Securities and Exchange Commission
100 F Street, NE.
; Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Farm Credit Administration
Federal Intermediate Credit Banks, and Production Credit 1501 Farm Credit Drive
Associations McLean, VA 22102-5090
9, Retailers, Finance Companies, and All Other Creditors Not Federal Trade Commission
Listed Above
Consumer Response Center
600 Pemnsylvania Avenue, N.W.
Washington, DC 20580
(877) 382-4357

TOWN OF WATERFORD
FIRE SERVICE VOLUNTEER
I hereby authorize the Town of Waterford to conduct a criminal history and identity check. I understand this Authorization is to be
part of becoming a Waterford Fire Service volunteer.
PRINT NAME: Last First ; Middle
OTHER NAMES YOU HAVE USED:
CURRENT ADDRESS:
Street Number & Name City State Zip
HOME PHONE #: BUSINESS PHONE #:
DATE OF BIRTH:
DRIVER'S LICENSE INFORMATION:
License number Expiration Date State of Issue
Please Answer the Following Questions:
Have you ever been involved in an incident involving domestic assault, child abuse or neglect? _ Yes _ No
If yes please explain details:
Do you have a valid Connecticut Drivers License? _ Yes No
Ifno, please explain details:
As a condition of volunteering, I give permission for the Town of Waterford to conduct a background check on me, which may include
a review of the sex offender registries, child abuse and criminal histories, and motor vehicle records. I hereby release and agree to hold
harmless from liability the Town. of Waterford, the officers and volunteers thereof, or any other person or organization that may
provide such information. I also understand that, regardless of previous appointments, the Town of Waterford and any of its agents are
not obligated to appoint me to a volunteer position.
APPLICANT/ SIGNATURE: . DATE:
PRINT NAME DATE:
Note: Submitting an incomplete or Heegible form may delay the backeround check results,
OFFICIAL USE ONLY: APPROVED Yes No

ABSTRACT OF DRIVING RECORD: RELEASE OF INTEREST
Employer, prospective employer, or volunteer organization
Town of Waterford (‘Company’).
Agent business name if acting on behalf of the company for employment purposes: Foley
rrier i L.
This is an authorization for release of my driving record for employment purposes, at my
employer's discretion for the full term of my employment.
l, employee, prospective employee, or volunteer or Independent
Contractor of the Company named above. To the extent permitted by law, | hereby provide
consent for Agent to provide a certified abstract of my complete driver's record, (including but not
limited to convictions, accidents, license suspensions or revocations, and any type of driver's
license that | possess) in any state where | hold or have applied for a driver's license. | further
provide consent for Agent fo provide and Company to use medical information about my physical
or mental health for purposes relevant to an employrnent determination, to the extent permitied
by applicable law.
Florida applicants only: | hereby provide consent for Agency to provide emergency contact
information contained in my motor vehicle records.
Georgia applicants only: | hereby provide consent for Agency to include photographs,
fingerprints, computer images, medical and disability information in my driving records.
Maryland applicants only: | hereby provide consent for Agency to report driving record entries
that are more than 3 years old, records of a first offense of driving with an alcohol concentration,
records or notations of probation before judgment, and records of the medical advisory board.
Montana applicants only: | hereby provide consent for Agency to report driving records of
traffic accidents that did not result In a conviction.
No employer, prospective employer, or their agent may use information contained in a driving
record related to the sealed juvenile record of an employee or prospective employee for any
purpose unless required by federal law. The employee or prospective employee must furnish a
copy of the court order sealing the juvenile record to the employer, prospective employer, or
their agent.
Drivers Name:
License Number:
Date of Birth:
Please attach a copy of License
Signature Date