If you are wishing to join please stop down at the station on Route 104 on any Tuesday after 7:00pm to pick up an application. Or you can print out this one.

ACTIVE MEMBERSHIP shall consist of male or female residents of the town of Scriba, New York, and who are over eighteen years of age and have been properly accepted into membership according to the by-laws. Active membership can consist of up to twenty (20) members living outside the town line, but not exceeding the Oswego River to the West, one (1) mile from the town boundaries to the South and East.  ACTIVE members are each allowed to vote in the affairs of the Corporation. ACTIVE members shall be approved by the county self-insurance plan and possess the necessary physical aptitude and technical training required to fight fires and perform rescue operation. All ACTIVE members are required to comply with the By-laws and acknowledge their agreement by signing them in the Secretary's records. 

Membership Application

Scriba Volunteer Fire Department.

PO Box 69, Lycoming, NY 13093

Last name                                                      First name                                                    M.I.

Address                                                       Apt #                             City / Town                                   Zipcode

Telephone # _______________________ 

SS#         -         -                        

How long have you resided at the above address?    Years ______    Months ______

Are you 18 years of age or older?                             Yes ____      No _____  (optional) Birth date           -      - 19      

Are you currently employed?                                    Yes ____      No _____  ( if Yes give employer information below)

Company ___________________________________

Address ____________________________________

Phone  (           )          -               

Do you have a valid New York State drivers license?   Yes _____  No _____

License #                                                                State _______________

Please indicate you availability tp participate in required SVFD activities ( meeting, drills, and Emergency calls)

Weekday                                                                        Weekends

   Days____ Evenings ____ Nights ____                            Days____ Evenings ____ Nights ____

Previous Emergency Services Experience?

Agency name/ type/ location__________________________________________________________

Have you ever been convicted or pled guilty to a Felony, Misdemeanor, Insurance Fraud, Arson, or a reduction of one of these offenses ?   Yes _____    No ______

OSHA regulations require that you pass a physical examination prior to becoming a firefighter. Which we shall provide. Will you be willing to undergo a medical exam?   Yes ____  No ____

Please list three personal reference, (others then member of this organization), who have known you for at least 3 years.

Name ____________________________________________   Phone #  (           )           -                    

Name ____________________________________________   Phone #  (           )           -                    

Name ____________________________________________   Phone #  (           )           -                    

WITH THE FREEDOM OF INFORMATION LAW, ALL INFORMATION CONTAINED/OR OBTAINED HEREIN WILL REMAIN CONFIDENTIAL AND WILL BE USED FOR INTERAL MEMBERSHIP PROCESSING.

IN WITNESS WHEREOF, THIS APPLICATION HAS BEEN SUBSCRIBED THIS ___________ DAY OF _________

20____ BY THE UNDERSIGNED APPLICATION WHO AFFIRMS THAT THE STATEMENTS MADE HEREIN ARE TURE UNDER THE PENALTIES OF PERJURY.

Applicant Signature ___________________________________      date ____________

Witnessed by ______________________________________        date ____________

Privacy notification

Section 94 of the public officers law ( personal privacy protection law) requires that you be notified of the following facts when information, which will be maintained in a record system, is collected from you.  The authority to request and confirm personal information on you is found in Article 6 of the Executive Law.

The information obtained will:

    Be used to determine your qualifications for the position for which you are applying;

    Be released to the Fire Chief and your potential supervisors; and

    Be maintained in your personnel file, (if you become a fire company member), or in our resume file foe six months (of you are not made a fire company member).

Failure to provide the information or authorization will result in you application not being considered foe membership.

Chief's of the Scriba Fire Department, will maintain the information.