Brigade Member Application - Murrysville Volunteer Fire Company

Brigade member guidlines Required

Check the box to acknowledge the following:

The minimum age to participate in the program is 19 years old with a minimum of 1 year of firefighting experience. Missing any of the credentials listed below could disqualify acceptance to membership.

Last Name

First Name Required

Middle Name Required

Date of Birth Required

Street Address Required

City

State

Zip Code

Years at this address Required

Phone #

Email

Driver's License #

Housing Status Required

Own Rent Live with parents

Sex

Male Female Other

Height

Weight

Marital Status Required

Spouse / Partner Name

Phone Number

Emergency Contact Name Required

Emergency Contact Phone # Required

Current Employer Required

Employer Phone Number Required

Previous firefighting experience Required

YES NO

Certifications Required

Check any certification currently held:

Essentials with Live Burn Basic Vehicle Rescue (NFPA 1006 or DOH) ISC 100, ISC 200, NIMS 700 Hazmat Operations (minimum with refresher within 1 year) Emergency Vehicle Operator (EVOC or equivalent) Pumps 1 CPR/AED First Aid Child Abuse Clearance (PA) State Background Check

Driver / Operator Required

Do you have previous experience as a driver of an emergency vehicle.

Description of Previous Firefighting Experience if any

Certifications

Upload certs here

Add files...

Shift Preference (Time) Required

Please indicate if you have a shift preference. If you are able to, or interested in both AM/PM shifts, select 'Both'.

Shift Preference (Day) Required

Please select the days that you would be interested in staffing for. Select all that would apply.

Place of Birth Required

Are you a Citizen of the USA? Required

YES LEGAL ALIEN (Green Card) NO

Military Service Required

Names of relatives or friends (current or past) in the Murrysville Volunteer Fire Company

Reference 1 Name Required

Reference 1 Phone # Required

Reference 2 Name Required

Reference 2 Phone# Required

Reference 3 Name Required

Reference 3 Phone # Required

Have you been refused membership or removed from any firefighting or EMS service? Required

Yes No

Are you under indictment for any crime? Required

Yes No

Have you ever been convicted of a crime in any court? (Other than traffic court) Required

Yes No

Are you a fugitive from justice? Required

Yes No

Do you have any driving citations? Required

Yes No

Do you have any physical limitations or disabilities? Required

Yes No

Do you have any medical conditions or allergies? Required

Yes No

Have you ever received workman's compensation for an on-the-job injury? Required

Yes No

Are you willing to submit for a physical evaluation within 30 days of acceptance? Required

Yes No

Anything else you would like to add?

I agree that the above information is true and complete Required

Yes No

Authorization 1 (Enter Name) Required

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) Required

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.

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

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