| Home Station:
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| Auxiliary Station:
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Applicant Name:
Last, First Middle
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Address:
Street Address, City, State, Zip Code
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| Home Phone:
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| Mobile Phone:
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| Work Phone:
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| Birthdate:
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| Last 4 Of Social Security #:
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| Email:
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| Marital Status:
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| Basic Requirements |
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| Are you legally authorized to work in the U.S.:
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Are you 18 years of age or older:
*If No, a work permit and a parental authorization is required, for ages 16 years & less than 18 years.
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| Do you possess a valid driver’s license:
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| Driver’s License Class:
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| Driver’s License Expiration:
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| Have you ever been convicted of a crime:
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| If you have ever been convicted of a crime, please explain:
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| Do you believe you are free of medical conditions that may preclude your participation as a volunteer firefighter:
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| Are you willing to participate in a medical exam/check required, after being accepted as a volunteer firefighter:
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| Does Height affect you:
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| Does Claustrophobia affect you:
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Do you understand that successful applicants are required to remain without facial hair to ensure a self-contained breathing apparatus mask will form a positive seal on the face:
(Moustache and short sideburns are acceptable as long as they don’t affect the seal)
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| Do you understand that applicants will be required to provide a criminal record check and background clearances:
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| Availability |
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| If accepted by the Volunteer Fire Department, you will be required to attend regular Tuesday practices/meetings (approximately 6:30pm – 10:00pm) Can you meet this requirement:
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| What days and hours are you available to respond to emergency calls:
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| Employment |
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| Are you currently employed or retired:
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| If employed, name of employer:
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| Address of Employer:
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Name of Employer 2 :
(If more than one employer)
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| Would Employer allow you to leave work for a call:
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| What time do you start work:
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| What time do you finish work:
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| Military |
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| Have you ever served in the U.S. Armed Forces:
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| If yes, what branch:
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| Type and date of discharge:
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| List any special training:
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| Education |
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| High School:
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| Graduate:
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| College/Trade School:
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| Degree:
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| Subject Major:
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| Skills - Experience - Training - Please indicate if you have any of the following skills or training |
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| Are you a certified Firefighter:
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| If you a certified Firefighter, what level:
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| Are you a certified Fire Officer:
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| If you a certified Fire Officer, what level:
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| Have you attended any fire and rescue schools:
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| If you attended any fire and rescue schools, please provide a copy of each certificate that you have received.:
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| Please list any skills or training that you feel relate to this position:
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| References |
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| Are you currently or have you ever been a member of a Volunteer Fire Department within Upper Macungie Township:
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| If you are currently or have you ever been a member of a Volunteer Fire Department within Upper Macungie Township, When were you a member:
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| Are you currently or have you previously applied for membership of another volunteer organization:
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| If you have you previously applied for membership of another volunteer organization, when:
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| Name of organization:
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| Person in charge:
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| Phone:
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| Do you know a member(s) of a volunteer fire department within Upper Macungie Township:
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| If yes, Name of Volunteer Fire Company member(s):
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| Previous Emergency Services Experience- Explain:
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| Previous Firefighter Experience-Explain:
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| Please provide three (3) references that are not related to you, whom you have known at least one year |
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| Reference #1:
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| Reference #1 Address:
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| Reference #1 Relationship:
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| Reference #1 Phone Number:
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| Reference #2:
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| Reference #2 Address:
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| Reference #2 Relationship:
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| Reference #2 Phone Number:
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| Reference #3:
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| Reference #3 Address:
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| Reference #3 Relationship:
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| Reference #3 Phone Number:
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| Emergency Contact Information |
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| Primary Emergency Contact Name:
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| Primary Emergency Contact Relationship:
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| Primary Emergency Contact Home Phone:
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| Primary Emergency Contact Work Phone:
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| Primary Emergency Contact Mobile Phone:
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| Secondary Emergency Contact Name:
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| Secondary Emergency Contact Relationship:
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| Secondary Emergency Contact Home Phone:
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| Secondary Emergency Contact Work Phone:
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| Secondary Emergency Contact Mobile Phone:
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| Additional Information (Voluntary) |
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Allergies :
(food, Medication, Insects, Etc.)
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| Statement of Certification and Understanding |
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| I hereby certify that I am :
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| Electronic Signature:
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The Volunteer Fire Departments within Upper Macungie Township provide equal opportunities to all volunteers/members and applicants and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
This applies to all terms and conditions of membership, including recruiting, placement, promotion, termination, recall, transfer, leaves of absence, compensation and training.
It is our intention that all applicants are given equal opportunity to successfully complete a six (6) month probationary period at the discretion of the Fire Chief of your home station before the final decision on team membership is brought to a vote by the organization.
Statement of Certification and Understanding
Read this application and your answers carefully before signing.
I certify that the statements made by me on this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that if I have knowingly made a misstatement of these facts, I am subject to rejection and/or removal as a member of the Fire Company. I further understand that if I knowingly make any false statements regarding my criminal history, it may result in my removal as a Firefighter.
It is acknowledged and understood that in order for me to be considered as a Volunteer Firefighter, I must meet one (1) of the criteria listed above. Should I no longer remain a member in good standing with a Volunteer Fire Department within Upper Macungie Township or remain an employee of Upper Macungie Township authorized to serve as a firefighter within the township, then I may no longer serve as a firefighter nor respond to emergency incidents. Failure to discontinue service as previously stated may result in appropriate criminal and civil actions being taken against me.
By signing my electronic signature above, I certify that the above conditions are understood and accepted.
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