BCCRS Full Membership Application

Facebook

This field is for validation purposes and should be left unchanged.

Membership Type Applying For

What Type of Membership Are You Applying For?*

Personal Information

Membership in the Montgomery County Fire and Rescue Service requires the completion of criminal history and reference/background checks. Candidates for membership will need to provide personally identifiable information including full social security and driver's license numbers at their initial interview. Candidates will also be required to submit fingerprints at a later stage in the process.

Name*

Address*

Home/Mobile Phone*

Mobile Phone

Work Phone

Email*

Date of Birth*

Are You a US Citizen?*

Yes
No

Do You Have a Drivers License?*

Yes
No

Drivers License Number

State

Class

Emergency Contact Information

Name of Emergency Contact*

Emergency Contact Address*

Emergency Contact Phone*

Name of Nearest Relative Not Living With You*

Nearest Relative Address*

Nearest Relative Phone*

Education

Last High School Attended*

Did You Graduate*

Yes
No

If No, Highest Grade Completed*

High School Address*

Did You Attend College?*

Yes
No

Name of College Attended*

Address*

Major Field of Study*

Degree/Diploma Awarded?*

Yes
No

Degree/Diploma Type*

Degree/Diploma Date

No. of Credits Earned*

Did You Attend More Than One College?

Yes
No

Name of Other College Attended*

Address of Other College*

Major Field of Study*

Degree/Diploma Awarded?*

Yes
No

Degree/Diploma Type*

Degree/Diploma Date

No. of Credits Earned*

Name of Current High School*

What Grade Are You In?*

Current High School Address*

Extracurricular Activities*

Do you participate in any extracurricular activities or sports? If so, please list them and provide the days and times.

Current or Most Recent Position/Job

Name of Current/Most Recent Employer

Current/Most Recent Position or Title

Current/Most Recent Employer Address

Dates of Employment (From/To)

Hours Per Week

Duties

Name of Supervisor

Employer/Supervisor Phone

Employer/Supervisor E-mail

May we contact your current/most recent supervisor for a reference check?

Yes
No
Please contact me first

Reason for Leaving

Previous Position/Job

Name of Previous Employer

Previous Position/Title

Previous Employer Address

Dates of Employment (From/To)

Hours Per Week

Duties

Name of Previous Supervisor

Previous Employer/Supervisor Phone

Previous Employer/Supervisor E-mail

Reason for Leaving

Military Service

Did You Serve in the Military?*

Yes
No

What Branch of the Armed Services Did You Serve?*

Number of Years Served*

Date of Discharge*

Type of Discharge*

General Information

Affirmative responses to the following questions will not automatically exclude you from being considered for membership. However, complete and accurate information must be provided.

Have you ever been dismissed of asked to resign from any position, weather as an employee, volunteer or otherwise?*

Yes
No

Please Explain*

Have you ever been cited for a traffic violation (not including parking tickets)?*

Yes
No

Please Explain*

Have you ever had a professional license suspended or revoked for any reason?*

Yes
No

Please Explain*

Have you ever been convicted of or pled guilty to a crime (felony, misdemeanor or other) - including being sentenced to probation before judgement, pleading nolo contendre, or being subject to a similar disposition?*

Yes
No

Please Explain

Have you ever been an applicant or employee or member of any fire department or rescue squad?*

Yes, Applicant
Yes, Member/Employee
No

Name of Department

Date of Application

Name of Department

Position(s) Held

Dates (From/.To)

Character Reference

List two references not related to you.

Reference #1 Name*

Reference #1 Position/Occupation*

Reference #1 Phone*

Reference #1 E-mail*

Reference #1 Address*

Reference #2 Name*

Reference #2 Position/Occupation*

Reference #2 Phone*

Reference #2 E-mail*

Reference #2 Address*

Short Essays

Short Essay*

In 100 words or less please explain why you would like to become a member of the Rescue Squad. Please list below any additional information you consider pertinent to your application for membership (including school honors, organization memberships, unique skills, etc.)

Future Plans*

Where do you see yourself three years from now?

Parent/Guardian Information

Parent 1 Name

First Last

Parent 1 Address

Parent 1 Mobile Phone Number

Parent 1 Work Phone Number

Parent 1 Email Address

Parent 2 Name

Parent 2 Address Same As Parent 1?

Yes
No

Parent 2 Address

Parent 2 Mobile Phone Number

Parent 2 Work Phone Number

Parent 2 Email Address

Signature Required

Please be sure you have signed and dated the form below and that you have answered every question clearly and completely. During you probationary class you will be required to perform a patient lifting ability test. This test has been designed to assure that applicants are able to participate in the necessary, physically demanding activities of the fire and rescue services. The testing procedures will be explained to you during your probationary class. Each applicant has two chances to pass the test. For reasons of safety, continuation of the application process is contingent on the passage of the test.

By signing below you are certifying that you are applying for a position with the Bethesda-Chevy Chase Rescue Squad and that you herby authorize the release of any and all information to the Bethesda-Chevy Chase Rescue Squad that we may request, from any of your records or files. Such information will include, but will not be limited to: military records, police records, credit records, banking records, arrest records, court records, traffic records, confidential records, educational records, employment records, etc. You also release all persons from any and all liability which could result from furnishing said information to the Bethesda-Chevy Chase Rescue Squad, Inc. or any of its agents. Further, you authorize the Bethesda-Chevy Chase Rescue Squad, Inc. to copy or otherwise reproduce this original document, and let such copied or otherwise reproduced copy act as the original instrument. The original document is to be retained on file with the Bethesda-Chevy Chase Rescue Squad and this authorization to release information shall not expire.

I, the undersigned, certify that I have read and fully understand this form in its entirety and that the information herein provided is true and complete to the best of my knowledge. I understand that, should any statement I have made prove to be false, misleading, or erroneous, it may result in the rejection of my application or in my discharge from the Rescue Squad.

Signature*

Date*

Parent Signature*

Date*

CAPTCHA

BETHESDA-CHEVY CHASE

RESCUE SQUAD

Fill Out The Form in its Entirety

Membership Type Applying For

Personal Information

Emergency Contact Information

Education

Current or Most Recent Position/Job

Previous Position/Job

Military Service

General Information

Character Reference

Short Essays

Parent/Guardian Information

Signature Required

BETHESDA-CHEVY CHASE RESCUE SQUAD

Phone