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Blanchard Township

Volunteer Firefighter Application Form

PO Box 135

Benton Ridge, Ohio 45816

NAME: ____________________________________________________________________

Last First MI

Are you 18 years or older? ____Yes ____No

Drivers License # ___________________ State ______ SS# _____________________

Address ________________________________________________________

City ______________________________________ State ______________ Zip ____________

Phone: Home: ___________________________ Work: ________________________________

Cell ____________________

Education: High School _________________________________________________________

Vocational School _____________________________________________________________

College: _____________________________________________________________________

Advance Education: ____________________________________________________________

Military: __ Yes __ No Branch: __________________ Highest Rank ___________

Dates ________________________

Fire/ Rescue Experience __ Yes __ No Fire Dept. ______________________________________

City / State __________________________________________ Highest Rank ________________

EMS Experience: __Yes __No First Responder __Yes __ No EMT __Yes __No

Paramedic __ Yes __ No

List all other training you may be willing to use in the Fire Service on the reverse side.

Blanchard Township

Volunteer Firefighter Application Form

PO Box 135

Benton Ridge, Ohio 45816

Check the usual times when you would be available to respond to emergencies:

Sun Mon Tues Wed Thur Fri Sat

6:00am to noon: ___ ___ ___ ___ ___ ___ ___

Noon to 6:00pm: ___ ___ ___ ___ ___ ___ ___

6:00pm to Midnight ___ ___ ___ ___ ___ ___ ___

Midnight to 6:00am ___ ___ ___ ___ ___ ___ ___

Do you have any medical conditions that would prevent you from doing physically demanding

Work of Firefighting? ____ Yes ____ No

If yes, List:______________________________________________________________________

Have you had a physical within the last 2 years? ___ Yes ___ No

List any allergies: _________________________________________________________________

Date of last Tetanus shot: __________________

After showing you the job description of a Volunteer Firefighter, do you know any reason why you would not be able to perform this work? ___ Yes ___ No

Do you carry liability insurance on all of your vehicles that you may drive while participating in Fire Department activities? ___Yes ___ No

Do you have health insurance? ___ Yes ___ No

Do you have any Felony convictions or DUI violations? ___Yes ___No

Do we have permission to run a back ground check? ___ Yes ___ No

Are you willing to submit to a drug test? ___Yes ___ No

In case of emergency, Notify __________________________ Relationship: ______________

Phone: ___________________

REFERENCES

List as character references three persons you have known for at least three years and who are related to you. May not be past employers.

NAME: ______________________________________________________________________

ADDRESS: __________________________________________________________________

PHONE #: ___________________________________________________________________

OCCUPATION: _______________________________________________________________

NAME: ______________________________________________________________________

ADDRESS: __________________________________________________________________

PHONE #: ___________________________________________________________________

OCCUPATION: _______________________________________________________________

NAME: ______________________________________________________________________

ADDRESS: __________________________________________________________________

PHONE #: ___________________________________________________________________

OCCUPATION: _______________________________________________________________

IMPORTANT INFORMATION READ CAREFULLY

EQUAL EMPLOYMENT OPPORTUNITY:: The Blanchard Twp. Vol. Fire Dept. values diversity in the workplace.

Men and woman of all ages, cultural and ethnic backgrounds, religious and political affiliation, national origins, and persons with disabilities are encouraged to apply.

TO APPLY: Complete and submit an official BLANCHARD TOWNSHIP FIRE APPLICATION FOR MEMBERSHIP form.

Applications shall be completed in full. We may wish to contact you by mail, email or phone. It is your responsibility to make sure contact information is correct and current. Except to accommodate the needs of individuals with disabilities, office personnel cannot write o applications. Any changes must be made by the applicant in person, or through signed, written communication. This application form is neither a guarantee of membership. CERTIFICATION AND AUTHORIZATION: I hereby certify that the statements are true and correct to the best of my knowledge. I understand that should an investigation disclose material misrepresentation, omission or falsification, my application may be rejected, or if a member, my membership and all rights and privileges of my membership may be immediately terminated. My signature on this application indicates that I have read the job description for the positions available to me and I understand that the job of a fire fighter is physically challenging and that my membership is dependent upon my successful completion of a physical examination conducted by a certified medical physician and that I receive it favorable background investigation. I authorize the investigation of all statements contained herein, and direct the custodian of any records relevant to the confirmation of these to release such information necessary for verification. I release any individual, institution, business or organization from any liability for damages, which might arise from the release of pertinent information. I have read, or have read to me, the statements above and my signature agree to these provisions.

Signature of applicant: __________________________________________________ Date : ____________________________

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