Volunteer Application

EMERGENCIES DIAL 9-1-1
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Personal History

Name
Address

Employment History

Address of Employer
May we contact your present employer?

Driving / Criminal History

Do you have any points against your license?
Have you ever been arrested or convicted of any criminal offense, including DUI?

Reference 1

Reference 2

Reference 3

Medical History

Do you wear glasses / contacts?
Do you have any hearing defects?
Do you have any speech defects?
Do you have high blood pressure?
Do you have a history of heart disease?

Areas of Interest

Indicate which area you are interested in:
Have you ever been a member of a fire, ambulance, or other service organization?
Have you ever had any fire, rescue, or ambulance training?
Do you know or are you related to anyone in the department?
Have you applied to this department before?
Have you applied to any other departments?

Miscellaneous Information

How did you find out about this position?
Drag & Drop Files, Choose Files to Upload
Drag & Drop Files, Choose Files to Upload

Attestation

I HAVE PERSONALLY COMPLETED THIS APPLICATION AND CERTIFY THAT TO THE BEST OF MY KNOWLEDGE IT IS ACCURATE AND TRUE. I ACKNOWLEDGE THAT THE WILLFULL WITHHOLDING OR FALSEIFICATION OF ANY STATEMENTS WILL IMMEDIATELY DISQUALIFY ME FROM BECOMING OR REMAINING A MEMBER OF THE TALLEYVILLE FIRE COMPANY. I HEREBY AUTHORIZE THE TALLEYVILLE FIRE COMPANY TO CONDUCT A COMPLETE BACKGROUND INVESTIGATION ON ME AS A CONDITION OF MY APPLYING FOR MEMBERSHIP. I AUTHORIZE ANY POLICE AGENCY, SCHOOL, DOCTOR, BUSINESS, OR ASSOCIATION TO RELEASE ANY PERTINENT INFORMATION, WHICH WOULD ASSIST THE TALLEYVILLE FIRE COMPANY IN EVALUATING MY CHARACTER AND QUALIFICATIONS.
Clear Signature
I hereby acknowledge and consent that my typed name above shall serve as my legally binding electronic signature for all purposes as allowed by applicable law. I understand that this signature has the same force and effect as a handwritten signature. Applicants under the age of 18 are not authorized to sign on their own behalf and must obtain a parent or guardians signature on a paper application.