WaterfordApplication

Town of Waterford Volunteer Firefighter Application
Page 1 of 7 
APPLICATION FOR MEMBERSHIP 
AS A VOLUNTEER FIREFIGHTER WITH  
THE TOWN OF WATERFORD FIRE DEPARTMENT
APPLY TO: 
TOWN OF WATERFORD
FIRE DEPARTMENT 
204 Boston Post Road
Public Safety Building
Waterford, CT  06385
The Town of Waterford Fire Department is dedicated to a policy of nondiscrimination in employment and
volunteer membership on any basis prohibited by law. Volunteer membership in the Town of Waterford Fire Department is
available without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran 
status, sexual orientation or any other legally protected status. 
PERSONAL INFORMATION 
APPLICANT’S NAME (LAST, FIRST, MIDDLE) 
STREET ADDRESS 
CITY/TOWN 
STATE/ZIP 
HOW LONG? 
TELEPHONE NUMBER (HOME) 
TELEPHONE NUMBER (CELL) 
E-MAIL ADDRESS
Are you either a U.S. citizen or an alien authorized to work in the United States? 
Yes____    No_____ 
If your authorization to work in the United States is subject to expiration, when will it expire? 
__________________ 
If membership is offered, can you produce documentation required by law to establish work authorization and identity? 
Yes____    No_____ 
Are you prevented from lawfully becoming employed in the U.S. because of visa or immigration status? Yes____    No_____ 
GENERAL INFORMATION 
Are there any days or times you would be unavailable to participate as a volunteer firefighter?  _____________________  
On what date would you be available to start? _______________________________________________________ ____  
Are you related by blood or marriage to any employee or elected official of the Town of Waterford?
Yes____  No_____ 
If yes, please name: ________________________________________________________________________________ 
Have you ever applied to, or worked for the Town of Waterford before?   ____________________    Yes____    No_____ If
yes, under what name, dates of employment and department?_____________________________________________  
Current employer: __________________________________________________________________________________ 
Employer Address: _________________________________________________________________Phone: __________ 
Position:________________________________________  Length of Service:_________________________________ 
Have you ever been denied membership to an Emergency Service, either paid or volunteer?             Yes____    No_____ 
If yes, explain: _________________________________________________________________________ 
OFFICE USE ONLY 
REC ________ _____ 
DRV ________ _____ 
PHY ________ _____ 
PRTS _______ _____ 

Town of Waterford Volunteer Firefighter Application
Page 2 of 7 
EDUCATION 
LEVEL 
SCHOOL NAME AND ADDRESS 
YEARS 
COMPLETED 
DIPLOMA/ 
DEGREE? 
Junior High 
  6    7  
 8 
High School 
  9   10   11   12 
College 
1      2  
 3   4   
Graduate/ 
Professional/ 
Trade/Business 
High School Equivalency Diploma (GED)?              Date __________ 
School _______________________________
Course of Study in Post-Secondary Education: ___________________________________________________________ 
Have you previously been a member of a fire department?  Yes ____  No _____  If yes, complete the following:  
Name of Department:____________________________________Address:_______________________________________ 
Name of Chief: _________________________________________ Telephone:____________________________________ 
Position:______________________________________ Reason for Leaving:  _____________________________________ 
List all certifications (including First Aid, CPR, EMT with expiration dates), trainings, licenses, special skills, courses of 
study or any additional information that you feel may be helpful to us in considering your application.  Use additional pages if 
necessary. 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
REFERENCES 
Give the names of three persons not related to you whom you have known at least one year. 
1.
__________________________________________________________________________________________
Name 
Address 
Phone 
Relationship 
2.
__________________________________________________________________________________________
Name 
Address 
Phone 
Relationship 
3.
__________________________________________________________________________________________
Name 
Address 
Phone 
Relationship 
IN CASE OF EMERGENCY PLEASE NOTIFY: 
________________________________________________________________________________________ 
Name 
Address 
Phone 
Relationship 
8
12
0

Town of Waterford Volunteer Firefighter Application
Page 3 of 7 
CRIMINAL BACKGROUND 
NOTE: THIS PORTION OF THE APPLICATION WILL ONLY BE REVIEWED BY MEMBERS OF THE HUMAN 
RESOURCES DEPARTMENT (OR THE PERSON(S) IN CHARGE OF MEMBERSHIP) AND ANYONE 
INVOLVED IN INTERVIEWING THE APPLICANT. 
Have you ever been convicted of or pleaded guilty or nolo contendere (no contest) to, a violation of any state, 
federal, county or municipal law? (Do not include minor traffic violations)  
Yes ______ 
No ______ 
If yes, please give information regarding the nature of the charge, the date and location of conviction and the final 
disposition of the case:   
Applicants are not required to disclose the existence of an arrest, criminal charge or conviction for 
which records have been “erased.”  The types of records subject to erasure under Connecticut law are 
as follows:  (a) a finding of delinquency or that a child was a member of a family with service needs; (b) 
a sentence as a youthful offender; (c) a criminal charge that was dismissed or “nolled”; (d) a criminal 
charge for which the person was found not guilty; and (e) a conviction for which the person received 
an absolute pardon.  Any applicant whose criminal records were erased will be considered to have 
never been arrested and may so swear under oath. 
I understand that the information provided above will not necessarily result in the rejection of my application, 
but that the nature of the information will be considered as it relates to the performance of the firefighting duties 
in question and in light of the requirements of state and federal law. 
Applicant’s Signature: ____________________________________________Date:________________________ 
NOTICE TO APPLICANTS REGARDING PRE-MEMBERSHIP DRUG TESTING 
Any individual applying for volunteer membership with the Town of Waterford Fire Department (the "Town”) shall 
submit to a urinalysis drug test as a mandatory part of the application process.  This notice serves as a written statement 
of the Town's intention to conduct such testing as part of the application process.  The testing will be conducted by 
a certified laboratory/testing service selected by the Town, in accordance with the procedures required by applicable 
state and federal regulations. 
Tested applicants will be given a copy of any positive test result.  All test results shall be considered 
confidential by the Town and shall not be disclosed to the employees of the Town, or any other person, other 
than to those persons for whom such disclosure is necessary.  Positive test results, or a refusal to sign this 
consent form and participate in pre-employment drug testing, shall be grounds for denial of membership. 
Arrangements for testing will be made by a representative of the Town, in consultation with each applicant. 
Cooperation in scheduling the testing is important for processing an application.   
By signing below, you consent to be drug tested and acknowledge you have thoroughly read the foregoing 
notice and policy, and you understand and agree that in order to be considered for membership with the Town 
of Waterford Fire Department, you will comply in full with the Town's drug testing policy.
___________________________________ 
_____________________ 
Applicant Signature 
Date 

Town of Waterford Volunteer Firefighter Application
Page 4 of 7
NOTICE OF BACKGROUND CHECK AND 
FAIR CREDIT REPORTING ACT DISCLOSURE 
As part of the interview process, the Town of Waterford may conduct a background check.  If you
are accepted for membership with the Town of Waterford Fire Department, the Town may also
conduct a background check in deciding whether to continue your membership and when making other 
membership-related decisions directly affecting you. As part of the background check, the Town may 
obtain a “consumer report” from a “consumer reporting agency.”  These terms are defined in the Fair 
Credit Reporting Act (“FCRA”), which applies to you. A consumer report includes information regarding 
such issues as your credit standing, criminal record, motor vehicle record, character and reputation.  If 
the Town obtains a “consumer report” about you, and considers any information in the “consumer 
report” when making a membership-related decision that directly and adversely affects you, you will be 
provided with a copy of the report before the decision is finalized.  You may also contact the Federal 
Trade Commission in Washington, D.C., about your rights under the FCRA as a consumer with regard 
to “consumer reports” and the “consumer reporting agencies” that prepare these reports.  Your signature 
below authorizes the Town to obtain consumer reports regarding you from consumer reporting agencies in 
connection with your application and during the course of your membership.  To perform the background 
check, please provide the following information: 
Social Security #   ______ - _______ - ________ 
Driver’s License #   ____________________________________________ State: ___________________ 
Print Name: _____________________________  
Any Other Names by Which You Have Been Known?_______________________________________ 
Date:______________________ Signature: ______________________________________________ 
PRIVATE AT-WILL MEMBERSHIP DISCLAIMER  
AT-WILL EMPLOYMENT DISCLAIMER 
PRIVATE APPLICANT'S AGREEMENT AND CERTIFICATION 
APPLICANT'S AGREEMENT AND CERTIFICATION 
I certify that the answers given in this application are true to the best of my knowledge. 
I understand that the use of this application form does not indicate that there are any positions open and 
does not in any way obligate the Town of Waterford.
I understand that should I be granted an interview, no representations that may be made at the interview 
are to be construed as creating any obligation, promise or contract on behalf of the Town.  
Further, in consideration of my membership as a volunteer firefighter with the Town of Waterford, I agree
to conform to the policies and procedures of the Town, as they may from time to time be implemented or 
revised, and that my membership can be terminated with or without cause, and with or without notice, 
at any time, for any lawful reason or for no reason at all at the option of either the Town or myself.   
I understand that false or misleading information given in my application, resumes, interview(s) or during 
the course of my membership may result in the withdrawal of a membership offer or termination of 
membership, whenever the omission or falsehood is discovered. 
I understand that acceptance for membership shall depend on satisfactory replies from my references 
and other background checks.  In the event I receive an offer of membership, I also understand that I 
may be subject to a drug test and/or a medical examination that I must pass before I commence 
working as a volunteer firefighter.  
I have read, understood and agree to the foregoing. 
_____
Signature of Applicant 
 Date 

Town of Waterford Volunteer Firefighter Application
Page 5 of 7
AUTHORIZATION TO COLLECT 
BACKGROUND INFORMATION 
I have applied for membership as a volunteer firefighter with the Town of Waterford.  I authorize
investigation of all statements contained in this application for membership as may be necessary in 
arriving at a decision. I authorize representatives of the Town to obtain pertinent information from 
my previous employers, references, and other persons with knowledge of my work history and 
background, financial history, education, regulatory or police records, driving records, licensing 
status or professional designation, and character or reputation, and to consider the information 
provided by the background check when making decisions regarding my membership as 
a volunteer firefighter with the Town of Waterford.
I authorize all previous employers, references or other persons having knowledge of my record or 
myself to release such information to the Town, and hereby release all persons from liability for any 
damage that may result from furnishing such information to the Town. 
A photocopy of this authorization may be accepted in lieu of the original. 
Signature: ______________________________Print Name: _____________________________ 
Print Former Name(s):_________________________________________________________ 
Date:  __________________________________ 
MOTOR VEHICLE CHECK 
By signing below, I do hereby give my permission and authorization for the Town 
of Waterford to obtain a copy of my Motor Vehicle Record.  The information obtained will be
used for company insurance, safety, loss control, job qualification, and/or compliance 
purposes.  If hired, or if currently employed, this release and authorization shall remain in 
effect during the term of my employment. The Town of Waterford reserves the right to run 
subsequent Motor Vehicle Reports on an as needed basis. 
______________________________________________ 
Signature 
___________ 
Date 
______________________________________________ 
Full Name 
___________ 
Date of Birth 
______________________________________________ 
Driver’s License Number  
___________ 
State of Issue 
_________________________________________________________________ 
Current Resident Address 

Town of Waterford Volunteer Firefighter Application
Page 6 of 7
Town of Waterford Fire Department
Disclosure for Consumer Report
The Town of Waterford Fire Department (Department) 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 
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 
 I have read and understand the FCRA Disclosure for Consumer Report
Town of Waterford Fire Department
Disclosure for Investigative Report
The Town of Waterford Fire Department (Department) may request an investigative 
consumer report about you from a third-party consumer reporting agency in connection to your 
employment or application for employment purposes (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 
perosnal 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, and/or mode of living. You may request more information about the scope 
and nature 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 
2S04, Melville NY 11747, telephone number 
(631)-557-0100, www.foleyservices.com
Name:
Phone:
SSN:
Sign:
Email:

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. 
1.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, or 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: ___________________________________________
You must provide at your own expense, an internet-connected device that is compatible with the minimum requirements
outlined below. You must 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 test of these
terms and Paste the text into a new document in a word processor or 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, 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, 2S04, 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 a choice as to whether you still want 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;
•
A personal computer or other device that is capable of accessing the internet. Your access to this page
confirms that your system meets these requirements.
•
An internet web browser that 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.
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 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.
I have Read, Understand, and Agree to Receive Notifications Electronically.
Page 7 of 7
Print Name:
Signature:
Date: