Hershey Volunteer Fire Company

B. Education History
Education History

Section B:
|Section B| Do you have either a High School Diploma or GED?*

YesNo
|Section B| School or Training?
Please include any colleges or any other schools attended.
|Section B| Special Qualifications
Licenses, skills with machines, other Fire Department memberships or related archives

E. References
References

Section E:
1. List Your References
Please list three persons who are not related to you and who have definite knowledge of your qualifications or fitness for membership. Do not use names of supervisors you listed above as we consider them references, unless otherwise noted.
|Section E| 1. Full Name*

First NameLast Name
|Section E| 1. Phone Number*

Area CodePhone Number
|Section E| 2. Full Name*

First NameLast Name
|Section E| 2. Phone Number*

Area CodePhone Number
|Section E| 3. Full Name*

First NameLast Name
|Section E| 3. Phone Number*

Area CodePhone Number
2. Criminal History
|Section E| Have you ever been convicted of a crime? Please include any misdemeanor or felony convictions. *
|Section E| If yes, list date of offense, all charges for which you were convicted and the disposition.
3. Medications
|Section E| Do you have any medical conditions or medications that would prevent you from your duties for the position you are applying for?*

F. Certification
Certification

Section F:
I affirm that the information contained in this application is true and correct to the best of myknowledge, information, and belief. If I am accepted into membership, I understand that I may berequired to undergo a medical examination as necessary to determine my fitness for duty. I realizethat any falsification in this application constitutes grounds for rejection or termination frommembership. In this regard, and unless I have indicated otherwise below, I authorize my present andpast employers to cooperate with the Hershey Volunteer Fire Company through its membershipcommittee and to release, on a confidential basis, any information regarding my employment7records. I understand that all of the information given will be considered in reviewing myapplication and is subject to investigation. If accepted for membership, I agree to abide by theHershey Volunteer Fire Company By-Laws and any rules and regulations which may apply. I furtherunderstand that my membership may be terminated at any time for any reason as provided by theHershey Volunteer Fire Company By-Laws, rules and regulations.
|Section F| Enter your full name which signifies your understanding and approval of the above statement.*
Today's Date

MonthDayYearHourMinutesAM/PM Option

G. Authorization for Release of Information
Authorization for Release of Information

Section G:
I authorize the Hersey Volunteer Fire Company to conduct an investigation into my background, including but not limited to anyrecord of Criminal Arrests which may exist, and to the release to the Hershey Volunteer Fire Companyany and all information obtained as a result of such investigation.
|Section G| Enter your full name which signifies your understanding and approval of the above statement.*
Today's Date

MonthDayYearHourMinutesAM/PM Option
I further understand that this investigation will be confidential and findings contrary to theinformation provided on the application may subject me to prosecution under the Pennsylvania crimescode for unsworn falsifications (18 PA. C.S. §4904). I understand that the information will be released tothe appropriate officers of the Hershey Volunteer Fire Company when the investigation is completed.
I verify that the information setforth in this application is true and correct. I understand that any falsification contained in this application shallresult in denial or termination of membership. This verification is made subject to the penalties ofsection 4904 of the crimes code of Pennsylvania(18 PA. C.S. §4904) Relating to unsworn falsifications.
|Section G| Enter your full name which signifies your understanding and approval of the above statement.*
Today's Date

MonthDayYearHourMinutesAM/PM Option

General Information