Thank you for your interest in joining us!
Please fill out each section of the application below. Someone from our department will contact you within the next few days.
Personal Information
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Phone Number 2
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Area Code
Phone Number
E-mail
*
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Country
Date of Birth
*
Social Security Number
*
Drivers License Number
*
Drivers License Expiration Date
*
State of Issue
*
Are you 18 or older?
Yes
No
If no, are you 16 or older?
Yes
No
Military Service?
Yes
No
If yes, what branch?
Are you a veteran?
Yes
No
Are you a past member of LVFD?
Yes
No
Have you applied for membership perviously?
Yes
No
What position are you applying for?
Education
School name
School type
Please Select
High School
College/University
Trade School
Other
Degree
Major or Emphasis
Last year Completed
School name
School type
Please Select
High School
College/University
Trade School
Other
Degree
Major or Emphasis
Last year Completed
School name
School type
Please Select
High School
College/University
Trade School
Other
Degree
Major or Emphasis
Last year Completed
List any applicable special skills, training or proficiencies.
List any certifications, licenses or similar credentials you have that would benefit of the position you are applying for (i.e. EMT, Fire Fighter I, etc.)
Prior Work Experience
Employer Name (most recent)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Job Title /Position
Dates of Employment
May we contact?
Yes
No
Employer Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Job Title /Position
Dates of Employment
May we contact?
Yes
No
Employer Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Job Title /Position
Dates of Employment
May we contact?
Yes
No
Criminal History
Have you been convicted of a felony or been incarcerated with a felony in the past seven years?
Yes
No
If yes, plese explain:
0/250
Have you been convicted of a misdemeanor, driving under the influence, simple assault, minor traffic violations, affray or disturbance of the peace within the past five years?
Yes
No
If yes, plese explain:
0/250
Have you had any motor vehicle accidents or been convicted more than once for any motor vehicle violations (except minor violations) within the past 5 years?
Yes
No
If yes, plese explain:
0/250
References
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Years Known
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Years Known
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Years Known
Prior Fire Department Experience
Fire Department
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Job Title /Position
Dates of Employment
May we contact?
Yes
No
Fire Department
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Job Title /Position
Dates of Employment
May we contact?
Yes
No
Acknowledgements
By submitting, I hereby certify that the above information, to the best of my knowledge, is correct. I understand that falsification if this information may prevent me from being hired, or lead to my dismissal if hired. I also provide consent for former employers to be contacted regarding my work records.
*
Yes, I agree / Understand
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
Name Parent/Guardian
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature Parent/Guardian
Waiver for Background Investigation
Waiver and Release for Background Investigation I am presently applying for employment as a member/firefighter/emergency medical technician with the Lebanon Volunteer Fire Department, Inc., which I acknowledge and understand, must thoroughly investigate my employment background, criminal history, personal background, education and references in order to evaluate my qualifications for a position as a member/firefighter/emergency medical technician. I understand that it is in the public’s interest that all relevant information in this regard, including my personal and employment history with my current and former employers, be disclosed to the Lebanon Volunteer Fire Department, Inc. By this release, I hereby authorize any representative of all of my former employers, which have been fully disclosed and identified in my employment application, to divulge any information in its files pertaining to my employment records and history, and I further authorize the release of such information upon request to any representative of the Lebanon Volunteer Fire Department, Inc. Also, authorize all former employers identified in my employment application to permit a review and full disclosure of all records, or any part thereof, concerning myself and my employment with those former employers, by and to any duly authorized agent of the Lebanon Volunteer Fire Department, Inc., whether said records are of public, private or confidential nature. The intent of this authorization is to permit all former employers identified in my employment application to provide, and for the Lebanon Volunteer Fire Department, Inc. to obtain, full and free access to the background and history of my personal life and my employment history and performance, for the specific purpose of permitting the Lebanon Volunteer Fire Department, Inc. to conduct a thorough background investigation regarding me that will provide pertinent data for consideration by the Lebanon Volunteer Fire Department, Inc. in determining my suitability for employment as a member/firefighter/emergency medical technician. It is my specific intent to provide the Lebanon Volunteer Fire Department, Inc. with access to personnel information, however personal or confidential it may appear to be. I authorize all former employers, which have been fully disclosed and identified in my employment application, to release any and all public and private information that it may have concerning me, my work record, my background and reputation, my military service records, educational records, my financial status, my criminal history record, including my arrest record(s) and records compiled during or as the result of a criminal investigation(s) of me, efficiency ratings, complaints or grievances filed by or against me, the records or recollections of attorneys at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have, or have had, an interest, attendance records, polygraph examinations, and any internal affairs investigations and discipline, including any files which are deemed to be confidential and/or sealed. I hereby release all former employers identified in my employment application, and, if applicable, their elected and appointed officials, employees and agents and all others from liability of damages that may result from furnishing the information requested, including any liability or damage pursuant to any state or federal laws. I hereby release all former employers identified in my employment application, and, if applicable, its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. I direct all former employers identified in my employment application to release such information upon request of the duly accredited representative of the Lebanon Volunteer Fire Department, Inc., regardless of any agreement, written or oral, I may have made with the former employer to the contrary. In addition, I also give the Lebanon Volunteer Fire Department, Inc. the right to thoroughly investigate my background, previous employment, education and references in order to ascertain my suitability for service as a Lebanon Volunteer Fire Department, Inc. employee. I release and hold harmless the Town of Lebanon, its elected and appointed officials, agents and employees from and against any and all liability which might result from conducting such an investigation, including any damages of whatever kind which may at any time result to me, my heirs, family or associates because of such investigation. I recognize and understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974, with regard to access and disclosure of records, and I waive those rights with the understanding that information furnished by any former employer will be used by the Town of Lebanon in conjunction with employment procedures. I understand that if a former employer refuses to cooperate with this investigation by failing to provide full disclosure of any and all relevant information about me, then the Lebanon Volunteer Fire Department, Inc. may disqualify me from further consideration for employment as a member/firefighter/emergency medical technician. A photocopy or facsimile of this release form will be valid as an original thereof, even though the said photocopy or facsimile does not contain an original writing of my signature. This waiver is valid for a period of three years from the date of my signature. Should there be any questions as to the validity of this release, you may contact me at the address listed on my employment application. I agree to indemnify and hold harmless the person to whom this request is presented, as well as his agents and employees, from and against all claims, damages, losses and expenses including reasonable attorney’s fees, arising out of or by reason of complying with this request.
*
Yes, I agree / Understand
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
Name Parent/Guardian
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature Parent/Guardian
Submit
Submit
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