APPLICATION FORM
VOLUNTEER FIRE DEPARTMENT
Town of Stark
The position you are applying for is a Paid-On-Call Volunteer Firefighter.
Personal Information
Name (Last, First, Middle): ___________________________
Address (City, State, Zip Code): ___________________________
Home Phone: ___________________________
Work Phone: ___________________________
Cell Phone: ___________________________
Are you under 18 years of age? ☐ Yes ☐ No
Employment Information
Name of Employer: ___________________________
Address of Employer: ___________________________
Would Employer allow you to leave work for a call? ☐ Yes ☐ No
Education and Training
High School, College, Trade School (Name, Yrs. Attended): ___________________________
College/Trade-related subjects studied: ___________________________
Any skills or training that you feel relate to this position: ___________________________
Fire Department Experience
Have you ever been a member of a fire department before? ☐ Yes ☐ No
If so, where? ___________________________
Chief’s Name & Number: ___________________________
Certifications and Health
First Aid Training? ☐ Yes ☐ No
Date last certified: ___________________________
Type of First Aid Training: ___________________________
Are you in good health? ☐ Yes ☐ No
If not, explain: ___________________________
Truck Driving Experience? ☐ Yes ☐ No
Driver’s License Classification: ___________________________
References
List three persons not related to you whom you have known at least one year, including at least one co-worker.
- Name: ___________________________
Address: ___________________________
Relationship: ___________________________
Phone #: ___________________________ - Name: ___________________________
Address: ___________________________
Relationship: ___________________________
Phone #: ___________________________ - Name: ___________________________
Address: ___________________________
Relationship: ___________________________
Phone #: ___________________________
Email Address: ___________________________
Gear Return Policy
Upon leaving the fire department, you have 30 days to return all gear. If not done, legal action may be taken.
Authorization
I certify that the information contained in this application (and accompanying resume, if any) is correct and I have not omitted any information. I understand that falsification or omission of information may disqualify me from further consideration for employment or result in immediate dismissal if discovered at a later date.
I authorize the schools, references, and my prior employers listed above to provide my record, and all other information they may have concerning me, and I release all parties from any and all liability or claims for damage whatsoever that may result therefrom.
Signature: ___________________________
Date: ___________________________