Tellico Village Volunteer Fire Department Inc.

Tellico Village Volunteer Fire Department Inc.
Applicant Information:
Applying for membership or administrative position?

Membership Administrative
Briefly describe why you are interested on TVVFD: *
Have you prior experience as a firefighter? *

Yes No
If yes, Department's Name, City and State.
Length of service
Briefly describe any prior Fire/Rescue/EMS training you have.
Are you currently National Registry Certified EMS?

Yes No
Certification level
License expiration date

Month Day Year
Date
Have you previously applied to another volunteer department? *

Yes No
If yes, please list the department(s) to which you applied, the dates and the outcome.
Enter any questions or other information about yourself that may help us respond.
Name of Applicant *

First Name Last Name
Date of Birth *

Month Day Year
Date
SSN *
Cell Phone *

Area Code Phone Number
Phone Service Provider *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Emergency Contact Name *
Emergency Contact Cell Phone *

Area Code Phone Number
Educational Information (Highest grade completed)
Advanced Degree in:
Name of last school attended
Do you agree to a driver's license record check? *

Yes No
License number *
Expiration date *

Month Day Year
Date
State *
Restrictions or endorsements
Current or prior CDL driver certification??

Yes No
Expiration date

Month Day Year
Date
Employment Information
Employment Status *

Working full-time Working part-time Seeking employment Retired
Business name, if working:
Approximate hours per week:
Length of service
Are you able to respond to emergencies during: *

Daytime Night Weekends Holidays
Do you have any prior military experience *

Yes No
Branch
Rank
Length of service
List any special or technical training
Medical Information

(Information will be kept confidential)
Do you have any allergies? *

Yes No
If yes, please explain
Do you have any physical or health limitations that could interfere with your performance in the job for which you are volunteering? If so, please explain. *
Are you able to lift/push/pull heavy objects? If not, state restrictions/limitations. *
If you are currently taking any prescribed medications, please detail.
Do you have any respiratory difficulties? If so, please explain. *
Do you have any hearing difficulties? If so, please explain. *
Primary Care Physician *
Office Phone Number *

Area Code Phone Number
Date of last physical examination *

Month Day Year
Date
Applicant Agreements:
I agree to have an annual physical examination as required by NIOSH National Institute Occupational Health Safety. You have the option of using your primary care doctor, (at your own personal cost) or if you elect to use the doctor approved by TVVFD (associated costs will be paid by the department).

I have not had a “Class A” driving violation or more than three “Class B” moving violations within the last three years.

If applying for Medical Division, I agree to complete the minimum EMS training to earn certification within the State of Tennessee as an EMR Emergency Medical Responder, including CPR & AED certification as well as a 6 hour course in Fire Safety, within a maximum of twelve months of acceptance into the department.

If applying for Fire Division, I agree to complete the minimum training including a basic CPR course, 16 hour introductory firefighter course and, later, a 64 hour advanced firefighter course.

If applying for the standard "dual" position, the required training for both Medical and Fire Divisions must be completed.

I agree to participate in Firefighter & EMS training provided by TVVFD.

I understand that I am expected to attend two regular training meetings per month and occasionally additional meetings and training as scheduled.

I understand that I am on a twelve month probationary period beginning the first day of the month of acceptance into the department and that I may be dismissed with or without cause during that period.

I understand that, due to occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. I am given the opportunity to be vaccinated with the hepatitis B vaccine at no charge to myself. Vaccination costs will be paid for by the TVVFD.

However, should I decline HBV vaccination at this time, I understand that I continue to be at risk of acquiring hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials and want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

I understand that Fire/EMS service activities are inherently dangerous and require strenuous physical activity.
Authorization and Understanding: Signature Date:

(Please read and sign below)
By my signing of this application, I represent that all of the information now or hereafter given by me in support of my application is true, accurate and complete. I understand that any misstatement, misrepresentation (including omissions) or falsification of this information is grounds for refusal of or acceptance and /or release from the department if discovered after being accepted.

I authorize you to verify any of the information concerning my employment, education, or medical history with the appropriate individuals, companies, institutions or agencies, and I authorize them to release such information as you require, including my disciplinary employment record, without any obligation to give me written notice of such disclosure.

I hereby release you and them from any liability whatsoever as a result of any such inquiries and disclosures. I agree that any false information in support of my application may subject me to discharge at any time during the period of my employment.
Signature *

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Date *

Month Day Year
Date
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Tellico Village Volunteer Fire Department Inc.

Applicant Information:

Employment Information

Medical Information

Applicant Agreements:

Authorization and Understanding: Signature Date: