Signup – Centereach Fire Department

Thank you for your interest in the Centereach Fire Department.

Please fill out the form below with all required information. If you cannot provide an answer please write “N/A”

Full Name *

Street Address *

State & Zip Code *

Date of Birth *

City *

Contact Information

Please provide as much contact information as possible. This allows us to easily reach you during your application process. Please remember to select the preferred method of contact on the form options below.

Home Number

Email Address *

Cell Number *

How would you like to be contacted? *

Home Cell Work Email

Work Number

Employment History

Your employer may be contacted for a character reference. If you are a student, please input this information clearly in the fields below. If you are currently unemployed, please enter "NA" in any of the relevant fields below.

Are you currently employed? *

Employer Information *

Can we contact your Employer? *

Prior FIRE/EMS History

If you've previously volunteered for another fire department or ambulance company, we'd like to know about it. If you're brand new to EMS, please feel free to enter "NA".

Do you have any prior Fire or EMS Service? *

Certifications: Please enter your highest Fire and EMS certifications. E.G: FF1, FF2 if you're EMS it could be EMT-B, EMT-CC and so on. If you have none, please enter "NA"

Highest Fire Certification *

Highest EMS Certification *

Previous Fire Dept. Name or Ambulance Co. Name *

Did you leave in good standing? *

If "NO" Please explain below

Have you ever been convicted of a crime? *

If "YES" Please explain below

Valid Drivers License? *

License Number *

Have you ever had your license suspended? *

If "Yes" Please explain below

By hitting submit you confirm that all information entered is accurate.

Upon submission, your information will be sent to one of our department chiefs for review and processing of your application. It may take up-to a week for an actual response from a member of our department.

Please forward any inquiries to info@centereachfd.org

Verification *