Membership Application – Perry Township Fire Department

TO REPORT AN EMERGENCY CALL 911

Perry Township Fire Department

Primary Phone Number

Secondary Phone Type

Secondary Phone Number

Employer Suite/Building

Employer Phone Number

Length of Employment

Past Employer Address

Past Employer Suite/Building

Length of Employment

Past Employer Phone Number

Level of Education

What prompted your application?

How did you hear about us?

Previous Fire/EMS Training

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

Note: A conviction / plea will not necessarily disqualify you for consideration.

To the Board of Directors of the Perry Township Volunteer Fire Department, Incorporated: I hereby certify that the information on this application is correct to the best of my knowledge. I have read the Letter to Applicant. You have my permission to contact references and to investigate my criminal and driving records and to furnish the information to any required agency. I affix my signature in evidence thereof.

TO REPORT AN EMERGENCY CALL 911

Perry Township Fire Department

Perry Township Fire DepartmentMembership Application

Perry Township Fire Department
Membership Application