Volunteer Application
|
| Date
|
|
| Name
|
|
| Prefix
|
|
| First
|
|
| Last
|
|
| Suffix
|
|
| Address
|
|
| Street Address
|
|
| Address Line 2
|
|
| City
|
|
| State / Province / Region
|
|
| Postal / Zip Code
|
|
| Country
|
|
| Phone Number
|
|
| DOB
*
|
|
| SSN
*
|
|
| Diver's License #
|
|
| Class of Driver's License and State of Issue
|
|
| Email
|
|
|
|
|
| Have you ever received a moving traffic violation? Yes or No. If yes, explain
|
|
| Have you ever been convicted of a felony? If yes, explain.
|
|
| Do you own a vehicle? If so identify Year, Make, and Model and Insurance Company and Agent.
|
|
| Is there any reason, medical or otherwise, that would prevent you from engaging in heavy lifting or strenuous activity? Yes/No If yes, explain:
|
|
| Name of Physician and Phone #
|
|
| Paragraph
|
|
| Name/Phone # of person to contact in case of emergency
|
|
| Highest grade completed in education and year completed.
|
|
| Have you ever served on a Fire District/Department before?
| Yes No
|
| Organization and years of service
|
|
| List any previous fire service training or certifications and reference
|
|
| List any previous EMS training or Certifications
|
|
| List your last 3 employers, job duties, length of employment, and reason for leaving
|
|
| Current Employer/Phone #
|
|
| Name of Supervisor
|
|
| Will your employer allow you to leave work to respond to a fire call?
| Yes No
|
| Do you know anyone currently a member of the Cooper County Fire Protection District
*
| Yes No
|
| If Yes, List:
|
|
| Please list below any comments, questions, or concerns:
|
|
| Type your initials and date if you accept the following statement:
| I, the undersigned, hereby certify that all information made on, or in connection with, this application is true and complete to the best of my knowledge, and I have not knowingly withheld any fact or circumstance. I understand that if any of the statements made by me on this application are false, or if a check with my current or former employers or references reveals that I would make an unsatisfactory employee, this will be sufficient grounds for rejection of my application or removal from employment. i hereby authorize my previous and current employers or and educational institutions I have attended to release to the Cooper County Fire Protection District any information they may have regarding my character, academic accomplishments, or employment history, whether on record or not. I also release any individual, partnership, or corporation which formerly employed me, its officers, agents, and employees of same or any educational institution from any liability for any damage whatsoever for issuing such information. I further understand that as part of the application process, a criminal history check and review of my driving record may be conducted by the CCFPD to ensure the accuracy of self-reported information. A drug screening may be required any time during tenure on the Department or before you are accepted.
|
|
Image Verification
|
|
|
|
|
|
EMF Free Form Builder
EMF Free Form Builder