Join Now 1. Applicant must make a photocopy of their driver's license and submit it with the application. 2. Applicants must answer every question HONESTLY and TRUTHFULLY and WITHOUT EVASION. 3. Any section of this application not filled out or any evasiveness to any of the questions in this application may result in AUTOMATIC DISQUALIFICATION for membership into the Commack Fire Department. 4. A thorough background investigation will be completed by the investigation committee of the Commack Fire Department. 5. An arrest record check will be conducted by the Suffolk County Police Department. 6. The arrest record release form MUST BE NOTARIZED. 7. All information contained in this application will be kept confidential.Personal DataDate MM slash DD slash YYYY Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneHome PhoneEmail List any other name, alias or nickname by which you are or have been known. Social Security Number Sex Male Female Date of Birth MM slash DD slash YYYY Citizen of USA Yes No Marital Status Single Married Separated Divorced Widowed If married, name of spouse Consent for Background CheckI, do hereby give my expressed permission to the Commack Fire Department to perform an investigation into my background. I am aware that mis may be an extensive investigation and may include, but not be limited to, verifying criminal history and driving record. First Middle Last Residence RecordStarting with your present address, list each address at which you have resided in the past 10 yearsAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency NotificationIn case of emergency, notify:Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship Phone - HomePhone - WorkPhone - CellEducation RecordSchool Level achieved Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dates Attended Military Service RecordList any military service performed on either active duty or on Reserve or National Guard status. Include Dates served, Branch, Rank, and Type and Date of Discharge.License RecordDo you possess a valid N.Y. State Drivers License? Yes No Type License Number Date Issued Date Expires Has any drivers license issued to you ever been suspended or revoked? Yes No If yes, explain When and Why Arrest and Summons RecordList <u>all</u> arrests including youthful offender treatment arrests which were dismissed, sealed, otherwise disposed of, and any cases pending. If you have never been arrested, enter <b>NONE</b>. Include Date, Location, Original Charge, Final Charge, and Disposition.List all summonses served upon you or on a vehicle owned by you, by a Law Enforcement Officer, Court, or other authority in any state, for violation of parking regulations, traffic regulations, or laws, or any other criminal law. If you have never received a summons or violation, enter <b>NONE</b>.MiscellaneousGetting up in the middle of the night to answer alarms Yes No Answering alarms in all types of weather Yes No Third Choice Do you agree to be a probationary firefighter for a period of 18 months? Yes No Do you agree to attend meetings and other functions of the Department? Yes No Have you ever been a member of any fire department or company, either volunteer or paid? Yes No If yes, please indicate Department Name, City State & Zip, Dates of Membership, and Reason for LeavingDo you have any other certificates Yes No If yes, please indicate Name, Department and YearDo you have First Aid Training? Yes No If yes, which type: Standard First Aid Advanced First Aid CPR/AED Training EMT EMT-CC EMT-P Other Are you aware that your personal vehicle is NOT covered by Fire Department insurance when responding to or returning from an alarm? Yes No Do you agree to attend Fire School and receive a Fire Fighting 1 Training Certificate within your probationary period? Yes No Do you agree to attend department, company and all other drills ordered by the Chief or any Officer? Yes No Briefly describe why you wish to become a volunteer member of the Commack Fire Department.Use the space below to complete any section, as necessary.DeclarationI, do hereby depose and say that I am the named person and that I have completed the foregoing questionnaire and that I understand the contents. I further state that the answers contained herein are complete and correct in every respect. I also understand that any material misrepresentation of facts may be cause for rejection before appointment or disqualification after appointment. First Last Please Upload a copy of your Photo ID / Drivers LicenseMax. file size: 50 MB.CAPTCHA