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 AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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 Submit If you are human, leave this field blank. Δ
