Recruitment Form Recruitment Form Please complete the form below and our recruitment committee will contact you to answer all your questions. Thank you. To become a member of the Rockville Centre Fire Department you must be 18 years of age, for a Jr. Firefighter 13 years of age or older, a resident of Rockville Centre, Baldwin, East Rockaway, Hempstead, Lakeview, Lynbrook, Oceanside, South Hempstead, or, NY, and pass a physical examination administered by the medical provider for the Rockville Centre Fire Department. Last Name * First Name * Middle Initial Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Email Address * Phone Number Best number to be contact at Best time to contact you 12:00 AM12:30 AM1:00 AM1:30 AM2:00 AM2:30 AM3:00 AM3:30 AM4:00 AM4:30 AM5:00 AM5:30 AM6:00 AM6:30 AM7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM6:30 PM7:00 PM7:30 PM8:00 PM8:30 PM9:00 PM9:30 PM10:00 PM10:30 PM11:00 PM11:30 PM I am interested in * Firefighter Emergency Medical Service Jr. Firefighter Program Do you have previous experience in the Fire/EMS service * Yes No If YES, please explain Comments/Questions reCAPTCHA If you are human, leave this field blank. Submit
