Personal Information Full Name (required) Birthday (required) Cell phone Social Sec No Street Address Desired Position Full Time EMTPart Time EMTFull Time ParamedicPart Time ParamedicVolunteer Your Email (required) Are you a U.S.citizen? YesNo Is the address above your permanent address? YesNo Have you ever been convicted of a crime? YesNo If yes, please explain: Do you have a driver's license? YesNo [group license-259] If Yes, what state?(2-letter abbreviation) Class Restrictions Operator Number [/group] Has your driver's license ever been suspended? YesNo If yes, please explain: Employment Current Employer Years at this company Employer's Address Employer's Phone Number Position/Job Title Previous Employer Years at this position Previous Employer's Address Previous Employer's Phone Job Title Military Have you ever served in the U.S. Armed Forces? YesNo If Yes, what branch? How many years? Type and date of discharge List any special training Education Name of High School you attended Dates Attended Vo-Tech or Trade School Dates Attended College Attended Dates Attended Degrees Earned Major Studies General Information List any special skills or certifications you have which would be of benefit to BTVFC Why do you want to join a volunteer organization? Are you currently or have you ever been a member of a volunteer organization such as BTVFC? If yes, name of organization Person in charge Phone Number Do you know a member of BTVFC? YesNo If yes, name of BTVFC member List 3 personal references: Reference 1: Name Phone Address How long have you known this person? Occupation Reference 2: Name Phone Address How long have you known this person? Occupation Reference 3: Name Phone Address How long have you known this person? Occupation Statement of Certification - Electronic Signature I, the undersigned, hereby claim that, to the best of my knowledge, all information provided in this application is true and correct. Further, I understand that any information which has been given incorrectly is cause for rejection or dismissal from the company. Permission is hereby granted to Bethlehem Township Volunteer Fire Co.,Inc. to contact any and all persons listed on this application, and any government agency which may have knowledge of my background. Your Name: Date Emergency Contact Information Name Phone Address Relationship Other Please leave this field empty. Please prove you are human by selecting the plane.
