Date of Application Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202320242025 Contact Information Last Name: First Name: MI: Phone: Email: Are you older than 18 years old as of this application date? Yes No Current Residence Street: City: State: MA CT Zip Code: Employment Current Employer: Occupation: References Reference 1: Contact Phone: Years Known: Reference 2: Contact Phone: Years Known: Fire and EMS Experience Department/Agency: Position: Certification and Process Can you perform any and all of the job functions of a fire fighter? Yes No I understand that the duties are physically challenging and that my membership will be dependent upon my successful completion of a medical exam and a drug screening to be conducted by a medical facility selected and approved by the Hampden Fire Department.By signing below, I hereby authorize and consent to undergo a background check including CORI and SORI to be conducted on behalf of HFD and I certify that the information provided on this application is accurate and complete. I understand and agree that misrepresentations or omissions in this application may result in termination of the application process or membership. Name: HFD does not discriminate against any applicant because of race, color, age, sex, religion, national origin or ancestry, marital status, sexual orientation, veteran’s status, or disability. Leave this field blank