Duchesne County Part Time Reserve Firefighter Application

The personal data collected on this form is classified as a public record and may be made available to the public as provided by Utah Code § 63G.2.201.

******************************************************************

To proceed with completing the Duchesne County Volunteer Application Form, please select the ‘Next’ button to continue

Duchesne County Part Time Reserve Firefighter Application
By continuing with the following form you agree that the following statements are true and correct: "Volunteer" means any person who donates service without pay or other compensation. Volunteers are not considered employees under the County Personnel Policies. "Volunteer" does not include any person who has been convicted of a criminal offense; and youth who has been adjudged delinquent; or any person or youth who has been diverted from the criminal or juvenile justice system and performs a public service as a condition of the person or youth's sentence, diversion, probation, or parole. Services rendered by a volunteer shall not be the same type of service which the person is otherwise employed to perform for the county. A volunteer may not donate any service to Duchesne County unless the volunteer's services are approved by the County Commission or the department head, and by the Office of Personnel. Volunteers are not covered by other provisions of the County's personnel policies, except they may be entitled to receive workers' compensation medical benefits. Reference: Utah Code 67.20.2
Full Name:

First NameLast Name
Email:
example@example.com
Phone:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name:

First NameLast Name
Emergency Contact Phone:
Format: (000) 000-0000.
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reserve Firefighter: (Complete this application to apply as a Reserve Firefighter for Duchesne County.)
Are you an active Red Card Holder:
Red Card #:
License Issued by (State):
Red Card Expiration:
Employment
Have you ever been employed by Duchesne County?
If Yes, please explain.
References: PROFESSIONAL ONLY

Professional Reference 1
Company / Position:
Start Date / End Date:
Email:
example@example.com
Phone
Format: (000) 000-0000.
Professional Reference 2
Company / Position:
Start Date / End Date:
Email:
example@example.com
Phone
Format: (000) 000-0000.
Professional Reference
Name:
Relationship:
Email:
example@example.com
Phone
Format: (000) 000-0000.

Military Service:
Are you a Veteran?:
Branch:
Rank at Discharge:
Please list your years of military service.

If you are still actively serving, please enter your start year and write ‘Active’ in the ‘To’ field.
From:
To:
Type of Discharge:
If not Honorable, Please explain:
Driver's License Number
Driver's License State
(Please submit a copy of your Driver's license with this form)
File Upload:

Cancelof
Are you a registered sex offender?
Have you ever been convicted of, pleaded "No Contest" or guilty for any offenses other than traffic violations? (A criminal record will not automatically bar you from volunteering)
If Yes, please explain:
Are you POST-retired with Utah Retirement Systems (URS)?
If Yes, please explain.

Vehicle Use Policy
Discriminatory Harassment
206.10.2 (Reviewed)
Volunteer Service Agreement
1. I agree to engage in only those activities assigned to me by an authorized representative of Duchesne County.

2. I understand and agree that in the course of providing volunteer services to Duchesne County, I may obtain knowledge or information which I otherwise would not have obtained. I agree that I shall not discuss or disclose any such information to anyone outside of the Duchesne County department from which I obtained such information.

3. In the course of providing volunteer services to Duchesne County, I shall abide by instructions and directions given to me by the volunteer organization and person in charge of volunteers.

4. I will not at any time hold myself out or represent to anyone that I am a paid volunteer or employee of Duchesne County.

5. I understand that I will receive no pay or compensation of any kind for the services I render to Duchesne County, and that my volunteer services may be discontinued and/or terminated by Duchesne County at any time and for any reason.

6. I understand and agree that I will be fully and completely responsible for unsafe actions, and that Duchesne County will not defend or indemnify me for any of my conduct while acting as a volunteer for Duchesne County.

7. I will defend, indemnify and hold Duchesne County harmless of and from any and all liability which may be incurred by Duchesne County as a result of any intentional and/or willful misconduct, criminal conduct or grossly negligent conduct provided by me to Duchesne County in connection with my volunteer services.

8. I consent and agree to provide a photograph of myself and submit to a full and complete background and criminal history check, both prior to and at any time during my volunteer service to Duchesne County.
I have read and do completely understand all of the above terms and conditions of my volunteer service to Duchesne County.
Volunteer's Initials:
Volunteer Acknowledgement
I do hereby certify that all of the statements and representations set forth in this application are correct and truthful. I have read the Duchesne County Volunteer Job Description and understand the requirements of this position.

Unless specified, all volunteer positions run for a 1 year period of time. We are most interested in volunteers who intend to commit themselves to the programs for an extended period of time. I hereby certify that I am obligated to give my best effort and maintain high standards of service and honor the confidentiality of clients and information.
Volunteer Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Right of Access Provider Waiver
Request to Obtain a Copy of My Utah Criminal History Record

I, the undersigned, am requesting a copy of my Utah Criminal History Record. I understand this record is protected by law (Utah Code Ann. §53-10-108) and may only be released to me by this agency if I appear in person with valid photo identification. This agency is authorized to retain a copy of this record.
Name

First NameMiddle NameLast Name
Previously Used Name(s) (Maiden, Alias, etc.):
Physical Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver License Number:
State:
Social Security #:
Please Inital the box that MOST Applies:
I wish to obtain a copy of my Utah Crominal History Record to take with me today. This agency may NOT retain a copy for any purpose.
Initials:
I authorize a release of my Utah Criminal History record, or any part thereof, by and to any duly authorized agent of this agency to accompany my employment, volunteer, licensing, permit application, or other expressed purpose approved by me today. Any information discovered may be used to consider my suitability for the urpose of my application.
Initials:
Applicant Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Third Party Release Form
Name:

First NameMiddle NameLast Name
Agency:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Duchesne County Part Time Reserve Firefighter Application

Employment

Military Service:

Volunteer Service Agreement

Volunteer Acknowledgement

Right of Access Provider Waiver

Third Party Release Form