Susquehanna Hose Company

Havre de Grace, MD

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Mission Statement:
To consistently achieve “Operational Excellence” and EXCEED our citizen’s expectations through Dedication of duty; Commitment to our membership and to those we serve; Maintaining the highest level of training skills; Instilling and communicating fire prevention within our community; Minimizing losses through aggressive mitigation techniques; and Maintaining a strong community presence, - While never compromising the Safety of our Firefighters, and never to forget those who served before us.

Susquehanna Hose Company Application, Background Check SOG & Substance Abuse/Testing SOG

Application For Membership

Personal & Contact Information

Address *
Address
Street Address 1
Street Address 2
City
State/Province
Zip/Postal
Do you have of the following conditions?
Have you ever been charged and convicted of any crime, to include misdemeanor offenses in this State or any other?

Education

Highest Level of Education
Do you have an:
College Degree

Driver Information

Have you ever been convicted of any offense other than a minor traffic violation? *

Emergency Contact Information

Address of Emergency Contact *
Address of Emergency Contact
Street Address 1
Street Address 2
City
State/Province
Zip/Postal

Employment Information

Current Employer Address
Current Employer Address
Street Address 1
Street Address 2
City
State/Province
Zip/Postal

Previous Membership & Experience

Do you have any physical impairment that may interfere with your performance with Susquehanna Hose Company? *
Have you ever applied for membership with Susquehanna Hose Company? *
Have you ever applied to another volunteer or career fire or EMS agency? Please list ALL agencies applied to-if more space is needed use reverse side of this application. *
Please indicate if you are a member of other fire/EMS agencies at this time. 
Attach Certificates

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List Three (3) persons not related to you for references

Address
Address
Street Address 1
Street Address 2
City
State/Province
Zip/Postal
Address
Address
Street Address 1
Street Address 2
City
State/Province
Zip/Postal
Address
Address
Street Address 1
Street Address 2
City
State/Province
Zip/Postal

PLEASE READ AND SIGN

Please acknowledge that by virtue of your signature, you understand that the Susquehanna Hose Company reserves the right and shall conduct a background check, through established sources certified to do same on behalf of this organization, as permitted under Maryland law.
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Contact Information

Susquehanna Hose Company
PO Box 58
Havre de Grace, MD 21078

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Phone

Emergency: 911
Phone: (410)939-4070