·LAKEWOOD FIRE DISTRICT NO.1 APPLICATION FOR FIREFIGHTER To the Applicant: Please mail the completed application/orm to the
following address:
Lakewood Fire District No.1
316 River Avenue
Lakewood NJ 08701
READ CAREFULLY PRIOR TO FILLING OUT APPLICATION INSTRUCTIONS
Read every question carefully. Answer every question, leave no blank spaces, if a question
does not apply to you, use ''Not Applicable", or "N/A". An applicant may be rejected who has
intentionally made a false statement of a material fact; and/or practiced, or attempted to practice
any deception or fraud in this application.
The applicant shall personally prepare this form. All entries, except the signatures, must be
hand written in black ink.
If the space provided for answering any question is insufficient, attach a separate sheet of paper
and include the question and question number above the answer or continuation.
All applications must be accompanied by copies (not originals) of Birth Certificate, Military
Service Record DD214 Form, High School Diploma or equivalent and Driver's License.
RELEASE AUTHORIZATION
To all Courts, Probation Departments, Selective Service Boards, Physicians, Hospitals, Employers, Educational
and other Institutions and Agencies without exception.
I,
am making application to Lakewood Fire District No.1. As a result, an
investigation is being conducted to determine my eligibility for membership/employment.
Therefore, you are authorized to release to Lakewood Fire District No.1 or its representatives, any and all
information documentary or otherwise pertaining to the above applicant that they may request.
I hereby release, discharge, and exonerate Lakewood Fire District No.1, its agents or representatives and any
person so furnishing information, from any liability of every nature and kind arising out of the furnishing,
inspection, or collection of such documents, records, and other information or the investigation made by
Lakewood Fire District No.1.
A photostatic copy of this authorization will be considered as effective and valid as the original.
Signature: ____________________________________
Date: - - - - - - - - - -
Witness Name (Print): _ _ _ _ _ __ _ _ _ __
Date: - - - - - - - - - -
Witness Signature: _ _~_________________
Date: - - - - - - -
2
FINGERPRINTING INFORMATION Name: -----------------------------------------Date of Birth: - - -'/- - -/ - -
Sex: - - - -
Race:
-----------
Height: _ _ __
Weight: _ _ __
Hair Color:
-
-----
Eye Color: ________
Place of Birth:- - - - - - - - - - - - - - - - - - - - - - - Citizenship: _________________________
Social Security Number: _ __
Current Address:
~~-------------~~---------~~~------
(Street)
(City)
(State)
Telephone Number: ________________
Employer and Address:
Occupation: _____________________ Scars, Marks, Tattoos, Amputations: ________________________________ Alias: ---------------------------------------------
Name and Address of Nearest Relative and Relationship: Driver's License Number:
----------------------- State:- - - - - - - - - -
3
PERSONAL DATA Attach Photograph In This Space 1.VVhatisyomfullnffiTIe? ____________________-=~------------------~-----------(Last)
(First)
(Middle)
2. Give any other names you have used or have been known by and attach a statement giving reasons.
A.
D. ______________________
B.
E. _ _ _ _ _ _ _ _ _ _ __
C.
F. _ _ _ _ _ _ _ _ _~__
3. Date of birth: __________-,----____(Month)
(Day)
Age at time of application: ____ (Year) Sex: ______ Height: ______ Weight: ______ Eye Color: _______ Hair Color: ________
4. VVhere were you born? ----,,--------,----__-----------,-::c--~------------(Hospital)
5. Birth Certificate:
(City)
(State) ------~------------------------------~-----
(City)
(County)
(State)
6. Check one of the following:
DAsian
DBlack (Non-Hispanic)
DWhite (Non-Hispanic)
7. Social Security Number: _ __
DHispanic/Latino DAmerican Indian/Alaskan Native DHawaiian NativelPacific Islander ------
Issued in which State: - - - - - - - -
4
RESIDENCE
8. Where do you currently reside?
(Number)
(County) .
(Street) (City)
(State)
(Zip Code)
9. How long have you resided at the above address? _ __ _ _ _ _ __
10. In chronological order, state each and every place in which you have lived during the past ten (10) years,
beginning with your present address:
From
To
Month Year Month Year Address (street, city, state, zip)
REFERENCES
11 . Give four references (Not relatives) who have known you well during the past FIVE years, excluding
firefighters for Lakewood Fire District No.1.
A. Complete Name: _ _ __ _ _ _ _ _ _ __ _ _ Number of Years Acquainted: _ __ Address:
Phone #: -----------------------------------Occupation: B. Complete Name: __________________________ Number of Years Acquainted: _ __
Address:
Phone #:
-------------------------------~
---------------Occupation:
C. Complete Name: _ _________________________ Number of Years Acquainted: _ __
Address: ------------------------------ Phone #:
Occupation:
----------------
D. Complete Name:_________________________ Number of Years Acquainted: _ __
Address:
------------------------------ Phone #: ---------------Occupation:
5
RESIDENCE
8. Where do you currently reside?
(Number)
(County) .
(Street) (State)
(City)
(Zip Code)
9. How long have you resided at the above address? _ __ _ _ _ _ __
10. In chronological order, state each and every place in which you have lived during the past ten (10) years,
beginning with your present address:
From
Month
To
Year Month Year Address (street, city, state, zip)
REFERENCES
11. Give four references (Not relatives) who have known you well during the past FIVE years, excluding firefighters for Lakewood Fire District No. 1. A. Complete Name: _ _ _ _ _ _ __ _ _ __ _ _ Number of Years Acquainted: _ __ Phone #: Address:
---------------------- -- - - - Occupation: B. Complete Name: _ _ _ _ _ _ _ _ _ __ _____ Number of Years Acquainted: _ __
Address:
- ------------------ ---- Phone #: -------------Occupation:
C. Complete Name:______________ __________ Number of Years Acquainted: _ __
Address: ----- --------------- - - ------ Phone #: --------- - - - - Occupation:
D. Complete Name: _ _______ _____________ Number of Years Acquainted: _ __
Address:
----------------------------- Phone #: -----------Occupation:
5
12. List the names of firefighters within New Jersey with whom you are personally acquainted:
Name
Address
Department
Phone #
EDUCATION
13. List chronologically (earliest dates first) all schools, colleges, and training courses you have attended:
School
Exact Address
Dates
From-To
# of Years
Attended
Type of
Degree
Graduated?
Yes or No
MILITARY SERVICE
14. Have you ever served in an active military organization of the United States? DYes
15. Give branch of service:
DNo
-------------------
16. Service Serial #: ------------------------17. How many discharges or separations from the service were given to you?
-----------------------
18. What is the type of your discharge(s) or separation(s)? (Honorable, dishonorable, honorable conditions,
medical, other, etc.) Be specific: __________________________________________________
Reason:
------- ---------------- - -- - - - - - - - - - - - -
19. Has your discharge or separation notice ever been corrected or changed?
DYes
DNo
20. What was the nature of the change? Changed from _ __ _ _ _ to_ _ _____
21. Were you ever court martial ed, tried on charges or were you the subject of a summary court, deck court,
Captain's mast, company punishment, office hours or any other disciplinary action?
DYes
D No
Number of occurrences: - - - - - If you answered yes to the above question, give details of charges, agency concerned, dates, dispositions,
location, and name ofmilitary base:
6
12. List the names of firefighters within New Jersey with whom you are personally acquainted:
Name
Department
Address
Phone #
I
EDUCATION
13. List chronologically (earliest dates first) all schools, colleges, and training courses you have attended:
School
Exact Address
Dates
From-To
# of Years
Attended
Type of
Degree
Graduated?
I Yes or No
,
I
MILITARY SERVICE
14. Have you ever served in an active military organization of the United States? DYes
15 . Give branch of service:
DNo
-------------------
16. Service Serial #: _ _______________________
17. How many discharges or separations from the service were given to you?
----------------------
18. What is the type of your discharge(s) or separation(s)? (Honorable, dishonorable, honorable conditions,
medical, other, etc.) Be specific: __________________________________________________
Reason:
---------------------------------------------
19. Has your discharge or separation notice ever been corrected or changed?
D Yes
DNo
20. What was the nature of the change? Changed from~_ __________ to___________
21. Were you ever court martialed, tried on charges or were you the subject of a summary court, deck court,
Captain's mast, company punishment, office hours or any other disciplinary action?
DYes
D No
Number of occurrences: - - -- - - If you answered yes to the above question, give details of charges, agency concerned, dates, dispositions,
location, and name of military base:
6
SELECTIVE SERVICE 22. Have you registered with the Selective Service?
0
Yes
ONo
EMPLOYMENT
23. Present Employer: _ _ _ _ _ _ _ _ _ _ _ _ _ __
Address:
~-~--------~~----~~--~~---~---------
(Street)
(City)
(State)
(Zip)
(phone)
Date Hired: - -- -- - Describe Job Duties:
24. List below chronologically, earliest dates first, each and every place you where previously employed since
the age of 18. OMIT NONE. Give correct, full addresses. Give dates of idleness between periods of
employment in proper sequence. Include all part-time employment.
From
Mo.lYr.
To
Mo .lYr.
Name and Address of
Employer
Position Held
25 . Were you ever discharged or asked to resign from employment? 0 Yes
hnmediate
Supervisor
Reason for
Leaving
DNo
If yes, give an explanation and details of discharge or forced resignation below:
7
26. Were you ever subjected to disciplinary action in connection with any employment? DYes
ONo
If yes, explain: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
27. Have you ever made application with this or any other fire department in New Jersey or any other State? DYes
DNo Department/Agency: _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ __ Present status of application: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Department/Agency: _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ __ Present status of application: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 28. Have you ever been terminated, asked to resign or rejected by another fire department for membership/employment in this state or any other state? 0 Yes
D No Department/Agency: _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ __ Reason: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
GENERAL
29. Have you ever used any narcotics, sl,lch as, but not limited to: marijuana, ecstasy, sleeping pills, barbiturates,
cocaine, hashish, PCP, LSD, steroids?
DYes
ONo
If yes, give extent of use and a specific explanation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ARRESTS, SUMMONSES, ETC.
30. Have you ever been arrested for or charged with a violation of the disorderly persons act or any city
ordinance in this state or any other state? DYes
0 No
8
If yes, complete the following:
Name of Charge, Arrest,
or Conviction
Date
Name & Address of Police Agency &
Court
Disposition
3 1. Have you ever been arrested, indicted, or convicted for any violation of the criminal law in this state or any
other state? DYes
DNo If yes, complete the following :
Name of Charge, Arrest,
or Conviction
Date
Name & Address of Police Agency &
Court
Disposition
32. Have you ever been fingerprinted? (Exclude only present application with this department)
DYes
DNo
If yes, complete the following:
Date
Location
Purpose
MOTOR VEHICLE HISTORY
33. Have you ever received a summons or a violation of the Motor Vehicle Laws in this state or any other
state?(Exclude overtime parking violations)
DYes
DNo If yes, complete the following: Date
Offense
Location
Court
Disposition
Your age
(at time)
Police Agency
9
34. Was your Motor Vehicle Registration Certificate, Driver's or other vehicle operator's license ever revoked in this state or any other state?
0 Yes 0 No If yes, which license? _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ _ _ __ Location: _ _ _ _ _ _ _ _ __ _ __
Reason: ---------------
35. Was your Motor Vehicle Registration Certificate, Driver's or other vehicle operator's license ever 0 Yes 0 No suspended in this state or any other state?
If yes, which license? _ _ _ _ _ _ _ _ _ __ Date: -------------
Location:
--------------
Reason: ---------------
36. If the answer to either of the two above questions was yes, was such Registration Certificate or Driver's
License ever restored? 0 Yes
0 No
Date: - - - - - - -
Location: - - - - - - - - - - - - - - - - - - - - - -
37. Have you ever been involved in a motor vehicle accident whether as a registered owner, operator,
passenger, or pedestrian, which resulted in any personal injury or property damage to you or anyone else?
DYes
DNo
Ifyes,explrun:__________________________________________________________
OTHER INFORMATION
38. Do you have any knowledge or information in addition to that specifically called for in the preceding
questions which is or which may be relevant, directly or indirectly, in connection with an investigation of your
eligibility and fitness for this membership/employment, including, but not limited to: knowledge or information
concerning your character, physical or mental condition, temperance, habits, employment, education, criminal
records, traffic violations, residence or otherwise?
DYes
ONo
Ifyes,explrun:___________________________________________________________
10
STATE OF NEW JERSEy........................ . .................................... . )ss. COUNTYOF ............................................................................. . I,
being duly sworn, depose and
say I am the above named person. I signed the forgoing statement. I personally read and printed by hand,
answers to each and every question therein and I do solemnly swear that each and every answer is full, true
and correct in every respect.
''Under Penalty of Law", a person who makes a false statement under oath or equivalent affirmation, or
swears or affinns the truth of such a statement previously made, when he does not believe the statement to
be true, is guilty of a crime ofthe fourth degree in violation of 2C:28-2.
(Applicant sign here)
State of:
County of:
Before me personally appeared the said
who says that he/she executed the above instrument ofhislher ·own free will and accord with full knowledge of the purpose therefore. Sworn to before me this _~_ _ _ _ _ day of_ _ _ _ _ year of _ _ _ _ __
My Commission expires: _ _ _ _ __
Notary Public--:--:----:------:-_ _ _ _ __
(printed name)
Notary Public --:-::-:-_ _:--_ _ _ _ __
(Signature)
Seal:
11
STATE OF NEW JERSEy ......................... '" ... . ............................. . )ss. COUNTYOF .. ................... . ....... .. .... .. ...... .... .. ...... .. ... .. .......... ... .. . I,
being duly sworn, .depose and
say I am the above named person. I signed the forgoing statement. I personally read and printed by hand,
answers to each and every question therein and I do solemnly swear that each and every answer is full, true
and correct in every respect.
"Under Penalty of Law", a person who makes a false statement under oath or equivalent affinnation, or
swears or affirms the truth of such a statement previously made, when he does not believe the statement to
be true, is guilty of a crime of the fourth degree in violation of2C:28-2.
(Applicant sign here)
State of:
County of:
Before me personally appeared the said
who says that he/she executed the above instrument ofhislher ·own free will and accord with full knowledge of the purpose therefore. Sworn to before me this
-----~-
day of._ _ _ _~ year of _ _ _ __
My Commission expires: _ _~_~_ Notary Public--:---:-----:-_-:---~_ _ _ __
(printed name)
Notary Public -::::-_~:--_ _~_ __
(Signature)
Seal:
11
LAKEWOOD FIRE DISTRlCT NO.1
AFFIDAVIT OF UNDERSTANDING
Social Security Nwnber
Print Last Name, First Name
Sample Question:
Have you ever been arrested, indicted, charged with or convicted for any violation of the
criminal laws in this State or in any other State? · YES
NO_ _ __
Since you are applying for a firefighter position, you must list all arrests and convictions.
Also, if you were arrested and found ''not guilty," your arrest will always appear on your
record. Remember, the question on the application states that you list all arrests. Arrests
are different from convictions. Words such as "conviction, not guilty or dismissal" are
the result ofthe arrest and should be listed in the column labeled: "Disposition." You
must list the original, chargeable offense for which you were arrested. For Example:
Name of Charge,
Date of Arrest
Arrest or Conviction
6110/00
Arrested for
Aggravated Assault
Narne and Address
Police Dept/Court
Lakewood Police 3ra
St. Lakewood. NJ
Disposition and/or
Sentence
Convicted of
Assault.
In this example, the original arrest was aggravated assault. You must list "aggravated
assault" not "assault" in the charge column. The conviction for assault is the result of the
downgraded charge and should be listed in the "Disposition" column. Dates and names of
the arresting authority must be accurate. Do not abbreviate. If you are not sure of any of
the charge dates, arrest, etc., mark "Not Sure" on your application. The correct
information can be submitted within five working days.
I have read the above and acknowledge I fully understand the information that is
required of me and that failure to supply all the correct information will be
considered willful falsification, which is adequate cause for removal from
membership/employment by Lakewood Fire District No.1.
Signature of Applicant
Date
Signature of Witness
DRUG TESTING APPLICANT NOTICE AND ACKNOWLEDGElVIENT I,
, understand that as part of the membership/employment process, Lakewood Fire District No. 1 will conduct a comprehensive background investigation to determine my suitability for the position for which I have applied. I understand that as part of this process, I will undergo drug testing through urinalysis.
I understand that a negative drug test result is a condition for membership/employment.
I understand that if I refuse to undergo the testing, I will be rejected for membership/employment. I understand that if I produce a positive test result for illegal drug use, I will be rejected
for membership/employment.
. I understand that if I produce a positive test result for illegal drug use, that information
will be forwarded to the Central Drug Registry maintained by the division of New Jersey
State Police. Information from that registry can be made available by court order or as
part of a confidential investigation to fire department membership/employment.
I have read and understand the information contained on this "Applicant Notice and
Acknowledgement" form. I agree to undergo drug testing through urinalysis as part of the
membership/employment process.
Signature of Applicant
Date
Signature of Witness
Date