Application for Employment

Your Full Name:

Address

Date of Birth:

Phone Number:

Cell Phone Carrier (If Applicable):

Email Address:

Drivers License Number:

Driver's License Issued By (State):

In case of Emergency, Please Notify (Name and Phone Number)

Are you a Legal Resident of the United States?

Yes

Position Desired:

Firefighter

EMT

Firefighter and EMT

List any experience that you may have had that would be helpful in this position:

If an Opportunity became available for Paid Standby, would you be interested?

Yes

Do you have any Felonies, Misdemeanors, or any Infractions on your Driving Record?

Yes

List any Felonies, Misdemeanors or Driving Infractions (N/A if Not Applicable)

Today's Date:

Education Level:

High School

Some College

College Graduate

List any Schooling or Certificates that may be applicable to Firefighting or EMS:

Have you served or are you currently serving in the Military?

Yes

Have you served or are you currently serving another Fire Department?

Yes

List any Fire Department you have Served, or are currently Serving (N/A if Not Applicable):

Do you have any Physical Limitations that would hinder you from performing this job?

Yes

If you have any Physical Limitations, Please Describe (N/A if Not Applicable)

First Beneficiary (Name, Address, and Phone Number)

Second Beneficiary (Name, Address, and Phone Number)

Please list three References other than Family (Name and Phone Number):

Chester Township Fire and Rescue