Online Firefighter Application

Madison Township Fire Department

66341 State Road 331

Bremen, Indiana 46506

Phone: (574) 633-4915

Name*

Date received

Date

Background/Reference Check completed

YES NOVote Date:

Background/Reference Check completed

Interview Date

Date

Vote Date

Date

Address*

Phone*

Social Security No.*

Email*

example@example.com

Are you a U.S. Citizen or an alien authorized to work in this country? Federal law prohibits the employment of unauthorized aliens. All persons appointed must submit satisfactory proof of employment and identity valid driver's license, birth certificate, Green Card, etc within three days of appointment. Failure to submit such proof within the required time shall result in immediate termination.*

YESNO

Are you between the ages of 18 and 65?*

YESNO

How were you referred to the Madison Township Fire Department?

Have you served in the Armed Forces of the United States?

YESNO

If yes, what branch?

Current Military Status

Why are you applying for this position? List all reasons why applying, and what personal qualifications you will bring to the Fire Department

Do you have previous firefighting and/or EMS experience?

YesNo

If Previous experience, when and what experience/certifications do you currently have?

When are you available?

Current Employer #1

Type of business #1

Address #1

Job title and duties #1

Supervisor's name #1

Phone #1

Previous Employer #2

Type of business #2

Address #2

Job Title and duties #2

Supervisor's Name #2

Phone #2

Have you ever been arrested?*

YESNO

If yes to being arrested, give full details

Do you have a Driver's License?*

YESNO

Drivers License # and State

Driver's License Type

Driver's License Expiration

Has your license ever been suspended?*

YESNO

If your license was suspended, why and when?

Have you ever been denied auto insurance?*

YESNO

If you have been denied, why?

Highschool: Name, City and State, Course/Major, Date attended, Did you graduate?

College: Name, City and State, Course/Major, Date attended, Did you graduate?

Trade/Vocational: Name, City and State, Course/Major, Date attended, Did you graduate?

**Please include a copy of any; certifications, diplomas, or training records that are relevant to your position on the fire department**

Have you had the Hepatitis B Series Vaccination?*

YES If yes, please bring a copy of your records to your interviewNO

Have you had a TB test?*

YES, If yes, please bring a copy of your records to your interviewNO

Do you have a current DOT Physical?*

YES, If yes, please bring a copy to your interviewNO

Emergency Contact Name #1*

Relation #1*

Address #1

Phone #1 (Cell/Home)*

Work Phone #1

Emergency Contact Name #2

Relation #2

Address #2

Phone #2 (Cell/Home)

Work Phone #2

Reference Name #1*

Relation #1*

Address #1

Phone #1 (Cell/Home)*

Years acquainted #1

Reference Name #2

Relation #2

Address #2

Phone #2 (Cell/Home)

Years acquainted #2

Reference Name #3

Relation #3

Address #3

Phone #3 (Cell/Home)

Years acquainted #3

It is our policy that equal employment opportunities be available to all members and applicants without regard to; race, sex, age, color, religion, national origin, participation in military services, disability, or any other protected status. The Madison Township Fire Department will comply with its obligation to provide reasonable accommodations to qualified

individuals with disabilities.

This application is not intended to be a contract. Any resulting appointment to the position of On-Call firefighter and its subsequent positions is for no fixed time and can be terminated at any time by either party. No individual other than the Chief of the Department, the Trustee of the Township, or the Township Board; has the authority to enter into any agreement for any specific period of time or to make any agreement contrary to the statements above. Any such agreement contrary to this must be in writing and signed into binding.

Further, any printed materials such as; policies, practices, handbooks, or other Department documents do not and are not intended to create any guarantee of employment. The Madison Township Fire Department has the right to modify or terminate policies, practices or other programs at any time.

RELEASE

I agree that the Madison Township Fire Department shall not be liable in any respect if my employment is terminated because of falsifying of; statements, answers or omissions by me in this application. I also authorize the Madison Township Fire Department to obtain information relevant to my bona fide qualifications from the; companies, schools, organizations and persons named above.

I hereby release said companies, organizations, schools, and persons from all liability for any damages for issuing this information.

I also understand that a physical examination is required and that periodic physical screenings will be required.

Signature of Applicant*

Date*

Date

Printed Name*

IN CASE OF AN EMERGENCY

REFERENCES