Volunteer Application
Volunteer Application
Your Full Name
Your Address
City
State
Zip Code
Telephone (Day)
Telephone (Evening)
Email Address
Driver's License Number
Social Security Number
Date of Birth
Present Employer
Present Employer Address
Occupation
Immediate Supervisor
Employer Phone Number
Typical Work Shift:
Does your Job require frequent travel out of the area?
Will your work shift hinder your ability to attend training sessions?
Are you currently an EMT
Are you currenlty certified in AHA CPR
Highest Leve of education
Have you Ever been a memeber of a fire department, rescue squad, or similar organization?
If Yes on previous question please explain
Reference #1 (references who are familiar with your education or work experience and not related)
Reference #2 (references who are familiar with your education or work experience and not related)
Reference #3 (references who are familiar with your education or work experience and not related)
Have you ever been arrested, summoned into court as a defendant or indicted, convicted, fined, imprisoned, or place on probation, or has any case been filed against you?
If Yes on previous question please explain in detail
List any comments and/or information which you feel is pertinent to your application process:
I authorize the Long Creek Fire Protection District, any consumer reporting agency or other outside service company engaged by said district for this purpose, now and subsequently, to obtain, prepare, use and furnish information concerning my current and former employment, education, credit, general reputation, health, personal characteristics and mode living, through correspondence or personal interviews with neighbors, friends or associates or others with whom I am acquainted or who may have knowledge concerning any of the above items. I further authorize the Long Creek Fire Protection District to obtain information form the Illinois State Police, the Federal Bureau of Investigation, the Illinois Secretary of State, or any other federal, state or local police or other agency regarding me in order to perform a criminal history/arrest record/driving record and background check. A copy of this authorization shall be sufficient for any party to release forgoing information about me to the Long Creek Fire Protection District. Upon written request I understand that said district will provide me with information regarding the scope of the investigation if one is made. I understand that reasonable efforts will be made by the Long Creek Fire Protection District to maintain any information which is obtained by means of this Authorization on a confidential basis with disclosure to be made only as needed to evaluate my qualifications for volunteer firefighter membership in the Long Creek Fire Protection District, however, I agree that I will release and hold the Long Creek Fire Protection, its officers, employees, and department members harmless with respect to any use, release, or dissemination of any information gathered by pursuant to this Authorization. By selecting yes I give the Long Creek Fire Protection District consent to perform a background check.
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