Membership Application – Perry Township Fire Department

Perry Township Fire Department
Membership Application

To apply for membership please complete all questions prior to submitting the form.

APPLICANT INFORMATION

Full Name

Address

Apartment/Building

City

State

Zipcode

Phone Number

At least 18 years of age?

Fire or EMS? Both?

APPLICANT LEVEL OF EDUCATION

High School

High School Address

City

State

Zipcode

College (If Applicable)

College Address

City

State

Zipcode

APPLICANT EMPLOYMENT HISTORY

Present Employer

Position

Employer Address

City

State

Zipcode

Country

Employer Phone Number

Length of Employment

Work Schedule

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Past Employer

Position

Past Employer Address

City

State

Zipcode

Country

Length of Employment

Past Employer Phone Number

Reference #1

Name

Phone Number

City

State

Zipcode

Reference #2

Name

Phone Number

City

State

Zipcode

Reference #3

Name

Phone Number

City

State

Zipcode

What prompted your application to Perry Township Fire Department?

Do you have any previous Fire/EMS Training? (Please explain and list certs.)

Indiana PSID#, if you have an issued number

Do you have any physical handicaps or disabilities that may interfere with your duties as a firefighter?

Yes No

If yes, please explain.

Have you ever been convicted or made a plea on a felony arrest?

Yes No

Have you ever been convicted or made a plea on a violation of Controlled Substance Laws?

Yes No

Please note that Perry Township Fire Department requires a background check.

I agree by signing that I give permission to Perry Township Fire Department to complete a full background check, call my employer for job verification, and to contact my references. I also certify that this application is completed with the correct and legal information to the best of my knowledge.

Signature

Signature Date

TO REPORT AN EMERGENCY CALL 911

Perry Township Fire Department

Perry Township Fire DepartmentMembership Application

Perry Township Fire Department
Membership Application