APPLICATION FOR FIREFIGHTER

Henrietta Township Fire Department
11732 Bunkerhill Rd. Pleasant Lake, MI 49272
phone: (517) 769-6656 fax: (517) 769-6123
APPLICATION FOR FIREFIGHTER
Date

MonthDayYear
Date
Driver License No.
Social Security No.
Name

First NameMiddle InitialLast Name
Present Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Length of time
Phone No.
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
E-Mail Address
example@example.com
EDUCATION: List name of school and last grade completed
Grade School
High School
College
Other
Present Draft Status
Are you an Armed Forces Veteran

YesNo
Branch of Service
Rank
Military Specialty
Type of Discharge

REFERENCES: List four responsible persons who are well acquainted with you, other than relatives.

Henrietta Township Fire Department
11732 Bunkerhill Rd. Pleasant Lake, MI 49272
phone: (517) 769-6656 fax: (517) 769-6123
Are you currently under indictment for a felony warrant?

YesNo
Have you ever been convicted of a felony?

YesNo
If Yes, give:
Charge
Court
Date

MonthDayYear
Date
Number of traffic tickets received (exclude parking tickets)
Has your driver's license ever been suspended or revoked?
Number of accidents involved in
Were you ever adjudged at fault in any accident?
CURRENT EMPLOYER
TYPE OF WORK
HOURS
PHYSICAL DISABILITIES:
Glasses
Respiratory Disorders
Hearing
Other
Any condition which will not permit any of the following:
Climbing
Wearing of Breathing Apparatus
Close Confinement
Easily Excitable
Any Physical Condition Which Will Not Permit Heavy Physical Exertion?
Any Training or Skills that you feel would be an asset to the Department?
I authorize investigation of all statements contained in this application further authorize all past employers and schools to release information to the Township of Henrietta, including but not limited to, attendance records, rating forms, written or verbal evaluations, and academic transcripts. I understand that misrepresentation or omission of facts called for on this application is cause for rejection or dismissal.
Date

MonthDayYear
Date
Signature
DO NOT WRITE BELOW THIS LINE
Interviewed by:
Date

MonthDayYear
Date
Rating: (1) Demeanor
(2) Attitude
(3) Presentation
(4) Ability to perform
Overall Rating
Remarks
AUTHORITY TO RELEASE PERSONAL INFORMATION

Henrietta Township Fire Department
11732 Bunkerhill Rd. Pleasant Lake, MI 49272
phone: (517) 769-6656 fax: (517) 769-6123
I hereby authorize the Township of Henrietta, to conduct investigation into my background including criminal history, previous employment, educational background, medical history, and conduct any other investigation that it deems appropriate.
I request any custodian of the aforementioned information including duly constituted law enforcement agencies or judicial officers or other appropriate persons to furnish the Township of Henrietta with all information it may have pertaining to me. I hereby release the Township of Henrietta, such custodian and any law enforcement agency, judicial officer, or any other individual from any liability arising from the disclosure of any information pertaining to me which is obtained during said investigation.
MY FULL NAME (please print):
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH

MonthDayYear
Date
DRIVER LICENSE NO.
SOCIAL SECURITY NO.
I hereby give permission to the release of any and all information as may be deemed necessary by the Township of Henrietta.
TYPE OR PRINT FULL NAME
Witness:
Signature:
Date:

MonthDayYear
Date
Date:

MonthDayYear
Date
Revised 01/14/00
Authority - Chief of Dept.
TITLE: HIRING PROCEDURES FOR PROBATIONARY FIREFIGHTERS

Henrietta Township Fire Department
11732 Bunkerhill Rd. Pleasant Lake, MI 49272
phone: (517) 769-6656 fax: (517) 769-6123
DISTRIBUTION: TWP. BOARD – S.O.P. MANUAL
1. Shall be at least 18 years old.
2. Shall provide the Chief a physician's report on the applicant's physical health at their own expense.
3. The probationary period shall be one (1) year with pay.
4. Shall attend fire drill once each month. (Two monthly meetings missed within the first year shall be cause for dismissal.)
5. Shall obtain a Medical First Responder License within two years of hiring.
6. Shall attend and pass an accredited M.F.F.T.C. Firefighter I training course within two years of hiring
7. Shall drive all trucks at least twice a month with either the Chief or Captain.
8. Shall, at time of driving, spend one hour learning equipment and operating pumps.
9. Shall attend any fire schools that their regular work and personal life will allow and has the Chief's okay.
10. Shall be responsible for obeying and following the rules and regulations of the department the same as the regular firemen.
11. Shall continue to drive trucks and study equipment at least once each month in addition to the regular fire drill.
12. An employee hired after October 1, 1998 shall be prohibited from wearing facial hair or long sideburns.
13. Shall attend a M.F.F.T.C. approved Haz-Mat, Awareness and Operations certified courses within two (2) years of hiring.
Should be Empty:

Henrietta Township Fire Department