KINGSFORD-UNION VOLUNTEER FIRE DEPARTMENT
Online Application
APPLICANT NAME
*
First Name
Middle Name
Last Name
APPLICANT ADDRESS
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
APPLICANT PHONE NUMBER
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
APPLICANT DATE OF BIRTH
*
-
Month
-
Day
Year
Date
EMERGENCY CONTACT
*
First Name
Last Name
Suffix
RELATIONSHIP TO EMERGENCY CONTACT
*
EMERGENCY CONTACT CELL PHONE
*
Please enter a valid phone number.
Format: (000) 000-0000.
BACKGROUND INFORMATION
The information provided in this section will be used to evaluate your suitability for employment, appointment, or volunteer service. Providing false, misleading, or incomplete information may result in disqualification from consideration or termination if already appointed.By completing this section, you authorize the organization to verify the information provided and to conduct background checks as permitted by law. You understand that this may include inquiries into criminal history, driving records, employment history, and other relevant records. All information obtained will be handled in a confidential manner and used only for official purposes related to your application.
Have you ever been convicted of any crime?
*
Yes
No
Conviction Date?
Conviction Charge?
Explain
Drivers License #
*
Issuing State
*
Expiration Date
*
I authorize Kingsford-Union Fire Department to conduct a drivers license check and a criminal background check prior to the application being accepted by the members of Kingsford-Union Fire Department.
*
EXPERIENCE
Please list your previous Fire Department work experiences.
Have you ever worked for a Fire Department?
*
Yes
No
Where?
Date?
Previous Fire Department Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for leaving?
Position(s) Held?
May we contact your previous department?
Yes
No
Previous Department’s Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Have you ever worked for an ambulance service?
Yes
No
Where?
Previous Ambulances Services Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Leaving?
Position Held?
May we contact your previous Ambulance Service?
Yes
No
Ambulance Service Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Specialized Training/Courses/Licenses Held?
PSID Number
If you do not currently have a PSID it is okay, one will be assigned to you at a later date.
MEDICAL INFORMATION
The information provided in this medical history section is confidential and will be used solely for determining fitness for duty and ensuring the safety of all personnel. Submission of this information is voluntary; however, incomplete or inaccurate responses may affect eligibility for participation or employment.By completing this section, you certify that all information provided is true and complete to the best of your knowledge. You understand that falsification or omission of medical information may result in disqualification or termination. This information will be kept confidential in accordance with applicable privacy and health information laws.
Do you have any physical or mental issues that would prevent you from doing your job as a firefighter?
*
Yes
No
If yes, please explain.
Are you currently on any medication?
*
Yes
No
If so, list the medications.
Medical History:
If any of the following conditions apply, please select all that apply to you.
Allergies
Bronchitis
Hay Fever
Hernia
Chronic Illness
Heart Disease
Epilepsy
Back Injuries
Claustrophobic
High Blood Pressure
Arterial Disease
Hearing Defect
Chronic Lung
Knee Injuries
Blurred Vision
Diabetic
Other
Have you ever had a Heart Attack?
*
Yes
No
Have you ever had a Stroke?
*
Yes
No
Do you have any allergies? (Including medications) List all
*
EDUCATION
Please select your highest level of education. A GED or High School Diploma is REQUIRED for acceptance of application.
Highest Grade Completed
*
9th
10th
11th
12th
Diploma or GED
*
Diploma
GED
EMPLOYMENT HISTORY (Last 3 Years)
Include Name, Address and Phone Number.
Employer #1
Employer #2
Employer #3
PERSONAL REFERENCES
Include Name, Phone Number and Relationship
Reference #1
First Name
Last Name
Reference #1 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference #1 Relationship
Reference #2
First Name
Last Name
Reference #2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference #2 Relationship
Reference #3
First Name
Last Name
Reference #3 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference #3 Relationship
CERTIFICATIONS
If you currently possess any certificates, please attach them below. If you have any Digital Certificates, please send them to kingsfordunionpresident@gmail.com with the subject "Certifications"
Fire 1&2
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Hazmat Ops & Awareness
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EMR
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EMT
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Paramedic
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CPR & First Aid
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Any Additional
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Why are you interested in joining the Kingsford-Union Fire Department?
*
I do hereby agree that the information contained herein is correct and true and that I understand that all information may be verified, at the direction of a duly appointed member of the Kingsford Union Fire Department. I also understand by signing that a Police background check will be conducted through the County of LaPorte. Any false information given will be grounds for automatic dismissal of this application and or termination of status with the department.
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