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Perry Township Fire Department
Membership Application
To apply for membership please complete all questions prior to submitting the form.
First Name
Middle Name
Last Name
Address
Apartment/Building
City
State
Zipcode
Primary Phone Type
Home
Work
Cellular
Other
Primary Phone Number
Secondary Phone Type
Home
Work
Cellular
Other
Secondary Phone Number
Email
Date of Birth
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
Age
Spouse's Name
Present Employer
Position
Employer Address
Employer Suite/Building
City
State
Zipcode
Country
Employer Phone Number
Length of Employment
Work Schedule
Past Employer
Position
Past Employer Address
Past Employer Suite/Building
City
State
Zipcode
Country
Length of Employment
Past Employer Phone Number
Level of Education
High School Grade 9
High School Grade 10
High School Grade 11
High School Grade 12
College 1
College 2
College 3
College 4
Masters 1
Masters 2
Masters 3
Masters 4
High School
High School Address
City
State
Zipcode
Country
College
College Address
City
State
Zipcode
Country
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.
Reference #1
First Name
Middle Name
Last Name
Phone Number
Address
Suite/Building
City
State
Zipcode
Country
Reference #2
First Name
Middle Name
Last Name
Phone Number
Address
Suite/Building
City
State
Zipcode
Country
Reference #3
First Name
Middle Name
Last Name
Phone Number
Address
Suite/Building
City
State
Zipcode
Country
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.
Signature
Signature Date
SUBMIT MY APPLICATION