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NEW YORK STATE DIVISION OF CRIMINAL JUSTICE SERVICES Office of Criminal Justice Operations Volunteer Firefighter Inquiry Form INSTRUCTIONS: This form is to be used only by a Sheriff’s Office (or OFPC, where applicable) when performing searches authorized under NY Executive Law §837-o in connection with individuals seeking membership in a Volunteer Fire Department. This form must be U.S. mailed, faxed or hand delivered between agencies. E-mail transmission is not permissible. Shaded boxes are required data elements. A. DATE: B. REQUESTING VOLUNTEER FIRE DEPARTMENT DEPARTMENT NAME: FIRE CHIEF NAME: SIGNATURE: ADDRESS: TELEPHONE NUMBER: FAX NUMBER: 1. NAME (LAST, FIRST, MIDDLE) 2. ADDRESS (Street, City, Zip Code) 3. ALIAS AND/OR MAIDEN NAME 4. SEX M F 5. RACIAL APPEARANCE White Black Indian Asian Unknown Other 6. ETHNICITY Hispanic Not Hispanic Unknown 7. HEIGHT Ft. In. 8. DATE OF BIRTH Month Day Year 9. PLACE OF BIRTH 10. SOCIAL SECURITY NO. RESULTS OF INQUIRY INVESTIGATING OFFICER: DATE (PRINT NAME/TITLE) INVESTIGATING OFFICER SIGNATURE NO RECORD OF AN ARSON CONVICTION OR A CONVICTION REQUIRING REGISTRATION AS A SEX OFFENDER CONVICTED OF ARSON; NO RECORD OF A CONVICTION REQUIRING REGISTRATION AS A SEX OFFENDER CONVICTED OF A CRIME REQUIRING REGISTRATION AS A SEX OFFENDER; NO RECORD OF AN ARSON CONVICTION CONVICTED OF ARSON AND CONVICTED OF A CRIME REQUIRING REGISTRATION AS A SEX OFFENDER DCJS-VFF (12/14)