Corning Joint Fire District

Corning, NY

Town of Corning

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CJFD Fire Fighter Experience Camp 2025 Application

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Membership Application

Personal Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Current Address(Required)

Street Address Address Line 2 City State ZIP Code

How Long at Current Address?(Required)

Prior Address

Street Address Address Line 2 City State ZIP Code

How Long at Prior Address?

Are You Currently Employed?(Required)

Yes

No

May We Contact Your Current Employer as as Reference?(Required)

Yes

No

Current Employer(Required)

Current Employer Phone(Required)

Have You Ever Been a Member of the United States Armed Forces?(Required)

Yes

No

Did You Receive a Dishonorable Discharge?(Required)

Yes

No

Detail Your Military Service(Required)

Have You Ever Been Convicted, Plead Guilty, Awaiting Trial for, or Served Any Sentence or Probation for a Felony or Misdemeanor Other Than a Minor Traffic Violation?(Required)

Yes

No

Please Give Date & Nature of Conviction(Required)

A Conviction does not necessarily exclude you from consideration.

How Did You Become Interested in Applying for Membership with the Corning Joint Fire District?(Required)

Education

Name of High School Attended(Required)

Address of High School Attended(Required)

Street Address City State ZIP Code

Did You Graduate High School?(Required)

Yes

No

Graduation Date(Required)

MM slash DD slash YYYY

Last Grade Completed(Required)

Did You Attend College, Trade, or Business School?(Required)

Yes

No

Name of College, Trade or Business School(Required)

Address of College, Trade or Business School(Required)

Street Address City State ZIP Code

Did You Graduate College, Trade, or Business School?(Required)

Yes

No

Last Grade Completed(Required)

Graduation Date(Required)

MM slash DD slash YYYY

Did You Attend Any Other School?(Required)

Yes

No

Name of Other School(Required)

Address of Other School(Required)

Street Address City State ZIP Code

Did You Graduate Other School?(Required)

Yes

No

Last Grade Completed(Required)

Graduation Date(Required)

MM slash DD slash YYYY

Section Break

Do You Have Previous Firefighter Training?(Required)

Yes

No

Please Provide NYS Training ID Number(Required)

Are You A NYS Licensed EMT?(Required)

Yes

No

What EMS Level?(Required)

License #(Required)

Date(Required)

MM slash DD slash YYYY

Are You A NYS Licensed CFR?(Required)

Yes

No

Date(Required)

MM slash DD slash YYYY

First Aid Certified?(Required)

Yes

No

Red Cross/AHA CPR Certified?(Required)

Yes

No

Please Attach Copies of All Valid Certifications & Training Certificates(Required)

Drop files here or

Max. file size: 200 MB.

Previous Member of Volunteer/Paid Department?(Required)

Yes

No

What Department?(Required)

Date From(Required)

MM slash DD slash YYYY

Date To(Required)

MM slash DD slash YYYY

Immediate Supervisors Name at Department(Required)

First Last

Department Phone(Required)

Your Availability to Assist Us(Required)

Weekdays

Weekends

Evenings

Any Hours

Other

List Any Skills/Experience/Training Whish You Feel Will Assist You in Performing Your Duties as a Member of this Department (IE: Mechanic, Electrician, Pump Operations, Etc.)(Required)

OSHA Regulations Require that you Pass a Physical Examination Before Becoming an Interior Structural Firefighter. The Departments Designated Physician Will Provide You With a Free Medical Examination. Will You Be Willing to Undergo a Medical Examination?(Required)

Yes

No

References

Please provide t he names and addresses of three (3) people not related to you, that you have worked with and to whom we may refer for a reference if necessary.

Reference #1 Name(Required)

First Last

Reference #1 Address(Required)

Street Address City State ZIP Code

Reference #1 Phone(Required)

Reference #2 Name(Required)

First Last

Reference #2 Address(Required)

Street Address City State ZIP Code

Reference #2 Phone(Required)

Reference #3 Name(Required)

First Last

Reference #3 Address(Required)

Street Address City State ZIP Code

Reference #3 Phone(Required)

Do You Have Any Friends/Acquaintances That Are Members Of This Organbization?(Required)

Yes

No

Please List The Names of Friends/Acquaintances That Are Members(Required)

Disclaimer & Signature

Are You Between The Ages of 16-18?(Required)

Yes

No

Disclaimer(Required)

I consent to the terms outlined below and certify that my statements are accurate:

I affirm that my answers are true and complete to the best of my knowledge. If this application leads to membership, I understand that false or misleading information in my application or interview may result in my termination or denial of membership.

Parent/Guardian Consent(Required)

I am the parent/guardian of the applicant and consent to the terms below:

I affirm that I am the legal custodial parent/guardian of the applicant and hereby consent to the membership of the applicant. I am aware of the risks associated with and the time requirements of being an active member of Corning Joint Fire District.

Applicant Signature(Required)

Parent/Guardian Signature(Required)

Δ

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Corning Joint Fire District Corning, NY

Corning Town Hall
25 South Elm Street
Corning, NY 14830

About CJFD
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Stations
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Phone

(607) 936-8287 x8

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