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Application Acknowledgment

Consent & Acknowledgment *

By beginning this application for membership with Harvest Volunteer Fire Department, I acknowledge and understand the following:

The application is a multi-step process and should take approximately 15 minutes to complete.
I may save my progress and return to complete the application within 7 days of starting.
All information I provide must be true, complete, and accurate to the best of my knowledge.
I understand that within 30 days of submitting my application, I will receive a background investigation packet and may be subject to a criminal background check and drug screening.
Any falsified information or failure to complete the required steps may result in disqualification from the application process.

By proceeding, I consent to these terms and voluntarily continue with the application process.

Personal Information

First Name *

Last Name *

Birthday *

Phone *

Email Address *

Confirm Email Address *

Street Address *

Apartment, suite, etc

City *

State *

ZIP / Postal Code *

Driver's License *

No file chosen

Upload a picture of your driver's license

Drivers License Number *

Drivers License State *

Marital Status

What is your average availability? *Weekday AMWeekday PMWeekend AMWeekend PMCheck ALL that apply

Health Information

Health Condition *ExcellentGoodBadPoor

Is there any reason that your present health condition would restrict your activities as a volunteer firefighter? *YesNoI'm Unsure

Please Explain:

Do you have health insurance? *YesNo

Policy Number

Insurance Carrier *

Employment Information

Current Employment

Employer *

Position *

Immediate Supervisor *

Supervisor's Number

How long have you been with this employer? *

Have been with your current employer for less than three (3) years? *YesNo

Previous Employment

Previous Employer

Position

Previous Supervisor

Supervisor's Number

How long were you with this employer?

Emergency Contacts

Contact Information #1

Name of Contact *

Phone Number *

Relationship *

Contact Information #2

Name of Contact *

Phone Number *

Relationship *

References

Reference #1

Full Name *

Phone *

Relationship *

Reference #2

Full Name *

Phone *

Relationship *

Reference #3

Full Name *

Phone *

Relationship *

Education

Do you have a Diploma or GED? *

Year Obtained *

Have you attended a Trade School?YesNo

Trade School

Year Completed

Certification/Degree?

Have you attended College?YesNo

College

Year Graduated

Degree/Major?

Related Experience

Do you have an medical certifications? *YesNo

Medical Certifications

Notice:

Please note, you will be required to turn in copies of these certifications to the training officer within 30 days of your acceptance.

EMT Level

License #

CPR Card Issuer

Renewal Date

Do you have any Fire related experience? *YesNo

Fire Certifications

Fire Certification Type

State

ProBoard #

Do you have any Military related experience? *YesNo

Military Experience

Military Branch

Military Specialty

Years of Service

Discharge Type

Background Information

Are you now or have you ever been addicted to alcohol? *YesNo

Are you now or have you ever been addicted to drugs (prescription or over-the-counter)? *YesNo

Have you ever been violent or had to attend anger management? *YesNo

Have you ever been accused of improper conduct toward a member of the opposite sex? *YesNo

Please Explain:

Have you ever been accused of improper conduct toward a child? *YesNo

Please Explain:

Have you ever been charged or convicted of a crime? *YesNo

Please Explain:

Have you ever been investigated, accused or suspected of arson by any governmental agency? *YesNo

Please Explain:

Have you ever had your driver’s license suspended? *YesNo

Please Explain:

Have you had any traffic violations within the past five (5) years? *YesNo

Please list them:

Have you ever applied for membership in the Harvest Volunteer Fire Department in the past? *YesNo

What was the outcome (not voted in, dismissed, etc.)

Do you currently know any member of the Harvest Volunteer Fire Department? *YesNo

What is/are their name(s)?

E-Signature

Sign Here

By signing above, I agree to the terms stated on the cover page of this application.

Date

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