|
| Personal Information |
|
| Last Name:
|
 |
|
| First Name:
|
|
|
| Middle Name:
|
|
|
| Date of Birth:
|
|
|
| Street Address:
|
|
|
| City:
|
|
|
| State:
|
|
|
| Zip Code:
|
|
|
| Years at this address:
|
|
|
Phone #:
10 digit phone number only
|
|
|
| Email:
|
|
|
Driver's License #:
Include State if different than address
|
|
|
Social Security #:
Numbers Only
|
|
|
| Housing Status: |
|
Own
Rent
Live with parents
|
| Sex: |
|
Male
Female
Other
|
Height:
Feet, Inches
|
|
|
Weight:
Pounds
|
|
|
| Marital Status:
|
|
|
| Spouse / Partner Name:
|
|
|
Phone Number:
10 digit phone number only
|
|
|
| Emergency Contact Name:
|
|
|
| Emergency Contact Phone #:
|
|
|
| Current Employer:
|
|
|
Employer Phone Number:
Direct Supervisor if applicable
|
|
|
|
| Background Information |
|
Place of Birth:
(City/State) for completing background check
|
|
|
| Are you a Citizen of the USA?: |
|
YES
LEGAL ALIEN (Green Card)
NO
|
| Previous firefighting experience: |
|
YES
NO
|
Description of Previous Firefighting Experience if any:
List Place and duration of service
|
|
|
| Military Service:
|
|
|
| Names of relatives or friends (current or past) in the Murrysville Volunteer Fire Company:
|
|
|
| Reference 1 Name:
|
|
|
Reference 1 Phone #:
10 digit number only
|
|
|
| Reference 2 Name:
|
|
|
Reference 2 Phone#:
10 digit phone number only
|
|
|
| Reference 3 Name:
|
|
|
Reference 3 Phone #:
10 digit phone number only
|
|
|
| Have you been refused membership or removed from any firefighting or EMS service?: |
|
Yes
No
|
| Are you under indictment for any crime?: |
|
Yes
No
|
| Have you ever been convicted of a crime in any court? (Other than traffic court): |
|
Yes
No
|
| Are you a fugitive from justice?: |
|
Yes
No
|
| Do you have any driving citations?: |
|
Yes
No
|
| Do you have any physical limitations or disabilities?: |
|
Yes
No
|
| Do you have any medical conditions or allergies?: |
|
Yes
No
|
| Have you ever received workman's compensation for an on-the-job injury?: |
|
Yes
No
|
| Are you willing to submit for a physical evaluation within 30 days of acceptance?: |
|
Yes
No
|
| Anything else you would like to add?:
|
|
|
|
| Authorization |
|
| I agree that the above information is true and complete: |
|
Yes
No
|
Authorization 1 (Enter Name):
By entering my name here, as a digital signature, I certify that this application was completed by me and that all the entries and information are true and complete to the best of my knowledge. I hereby authorize Murrysville Volunteer Fire Company #1, it's agents, my employer(s), references and local and state police to furnish and information concerning my character, habits, health, history or employment. I hereby release all such persons from any and all liability or damages on account of having furnished this information, medical, criminal or otherwise.
|
|
|
Authorization 2 (Enter Name):
By entering my name here, I hereby agree that I am requesting to join the Murrysville Volunteer Fire Company #1 on a one year probationary basis and that I may be terminated during this period as the sole discretion of the Murrysville Volunteer Fire Company #1. I hereby agree that the information supply in this application will be used for the purposes of investigation. I also fully understand that I may be denied membership if I do not live or work in the district of the Murrysville Volunteer Fire Company #1.
|
|
|
Parent / Guardian Authorization (Enter Name):
If the applicant is under 18 years of age, a parent or authorized guardian must sign here. -- As the parent / legal guardian of the applicant, I authorize and attest to the same requested and stated in this application.
|
|
|
Thank you for your interest in the Murrysville Volunteer Fire Company!
Someone will contact you soon to schedule an in-person interview; a copy of this application will be sent to the email entered above.
Click SUBMIT below when finished
|
