Volunteer Application

Equal access to program, services and employment is available to all persons. Those applicants requiring reasonable accommodations to the application and/or interview process should notify the Fire Chief, Recruit & Retention Coordinator or Training Officer.

Name*

First NameMiddle NameLast Name

Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Interested in:*

Social Security Number

Date of Birth

Date

Oregon Driver's License number

Date available to start

Date

Have you ever been convicted of a felony?

YesNo

If accepted by the Fire Department, you will be required (unless other wise excused by Training Officer) to attend regular weekly Thursday Drills (7:00PM to 9:00PM). Can you meet this requirement?

YesNo

Do you believe you are free of medical conditions that may preclude your participation as a volunteer firefighter?

YesNoI may need accommodations

Are you willing to participate in a medical check required of potential volunteer firefighters (NFPA 1582)?

YesNo

Do you understand that volunteer firefighters are expected to be in good physical condition, and do you feel you are physically able to participate in a physical fitness related test as part of the Certification process?

YesNoI may need accomodations

Do you understand that successful applicants are required to remain without unapproved facial hair to ensure a self-contained breathing apparatus mask will form a positive seal on the face?

YesNo

Do you understand that in order to be available for emergency call-outs, you must be able to arrive at the fire station promptly and have abstained from alcohol and drugs for the previous 8 hours?

YesNo

Do you understand that in order to respond to emergency call-outs, you must complete specific training prior to responding on calls?

YesNo

Are you willing and able to respond to emergencies?

YesNo

Are you willing and able to participate in the occasional weekend training?

YesNo

Times available for calls and/or training.

Below list 3 references not work or family related. (You are authorizing Lookingglass Rural Fire District to contact the References listed.)

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Below list 3 work references. (You are authorizing Lookingglass Rural Fire District to contact the References listed.)

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

List 5 years of Job experience.

Please check the certifications you currently hold

CPR - Cardiopulmonary resuscitationCertified Trade - mechanic, electricianFire Safety Systems - alarms, extinguishersRescue procedure - lifeguard, auto extricationFirst AidKnowledge of breathing apparatus - scuba diving, etcPAD/Defibrillation TrainingOccupational Health & SafetyOther

The Lookingglass Rural Fire District assures fair Treatment of applicants and employees in all aspects of personnel administration without regard to ploitical affiliation, race, color, national origin, age, sex, religious affiliation, marital status, disability, veteran status, sexual orientation, genetic information or any other protected class under State and/or Federal law and with proper regard for their privacy and constitutional rights as citizens.

Applicant Statement:

I certify that all information I have provided in order to apply for and secure work with the Fire District is true, complete and correct. I understand that any information provided by me that is found to be fals, incomplete or misrepresented in any respect, will be sufficient cause to cancel furhter consideration of this application or immediately discharge me from the Lookingglass Rural Fire Districts service, whenever discovered.

I understand that the Lookingglass Rural Fire District does not unlawfully discriminate in employment and no question on this application is used for purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state and/or federal law.

If I am hired, I understand that I am free to resign at any time, with or without prior notice, and the employer reserves the same right to terminate at any time, for any lawful reason and without prior notice except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period of definite duration. I understand that no supervisor or representative of Lookingglass Rural Fire District is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the Fire Chief.

I also understand that if I am hired:

I will be reuired to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard;
I authorize the Lookingglass Rural Fire District to verify the employment and education information provided in this application.
I authorize my driving record to be checked if the position I am applying requires driving.
I understand and agree to be subjected to a pre-employment drug screening and criminal history background check, if applicable.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand, and accept all terms of the foregoing Applicant Statement. I further Acknowledge that no offer or promise of employment has been made to me at this time.

Signature

Lookingglass Rural Fire District

Skills and Experience