Thank you for your interest in the Lineboro Volunteer Fire Department. Please make sure to carefully read, completely fill in, sign, and date all requested information. Digital applicants must be at least 18 years of age. If you are under 18 years of age, please print an application and be certain to have a parent or guardian sign and date as well. All completed applications will be reviewed by the Financial Secretary for processing. Please note that in order for your application to be processed there is a $5 application fee. You must be present at a company meeting for your application to be accepted; meetings are held on the first Wednesday of every month at 7:00 PM. We are looking forward to seeing you in the future.

Let it be understood and agreed that any misrepresentation of any information on this application will be sufficient grounds for dismissal of this application or termination from the Lineboro Volunteer Fire Department if I am accepted as a member. I also agree to abide by any rules the Lineboro Volunteer Fire Company sets forth upon my becoming or remaining a member. I agree to allow the Lineboro Volunteer Fire Department to verify my background as a condition to belong to the Lineboro Volunteer Fire Company Inc. Applicants under the age of eighteen must have their parents’ or guardians’ permission to belong and participate in activities. All applications are the property of the Lineboro Volunteer Fire Department Inc and are not for public review.

The Lineboro Volunteer Fire Department Inc. is an equal opportunity organization, dedicated to a policy of non-discrimination of membership on basis including race, color, gender, religion or national origin.

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PERSONAL DATA
Name: Last, First, Middle
Home Address:
Mobile Phone:
Home Phone:
Gender:		Male Female
Email Address:
Social Security Number:
Drivers License Number:
State:
Type:		Select Below Class A CDL Class A Non-Commercial Class B CDL Class B Non-Commercial Class C Learners Permit
Has your driver's license ever been suspended and/or revoked?:		Yes No
If yes, explain why:
EMERGENCY POINT OF CONTACT
Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Address:
Emergency Contact Phone:
FIRE/RESCUE EXPERIENCE (If Applicable)
Prior/Current Fire Department Membership:		Yes No
Department 1 Name:
Department 1 Address:
Department 1 Years of Service:
Department 1 Title/Rank:
Department 1 Phone Number:
Department 1 Member in Good Standing:		Yes No
Department 2 Name:
Department 2 Address:
Department 2 Years of Service:
Department 2 Title/Rank:
Department 2 Phone Number:
Department 2 Member in Good Standing:		Yes No
List any Fire/EMS Certifications that are current: Please attach copies of certifications
Upload Certifications:		Add files...
EDUCATION
Do you possess a high school diploma or GED?:		Yes No
If yes, date received:
If no, list last grade completed:
High School Attended: Name, City, State
College/University 1 Name:
College/University 1 City/State:
College/University 1 Degree Type/Major:
College/University 1 Dates Attended:
College/University 2 Name:
College/University 2 City/State:
College/University 2 Degree Type/Major:
College/University 2 Dates Attended:
MILITARY SERVICE
Branch of Service:
Rank at time of Discharge:
Date of Entry:
Date of Discharge:
EMPLOYMENT
Current Employer:
Current Employer Address:
Current Employer Job Title: Describe Duties
Current Employer Name and Title of Supervisor:
Current Employer Hire Date:
Previous Employer:
Previous Employer Address:
Previous Employer Job Title: Describe Duties
Previous Employer Name and Title of Supervisor:
Previous Employer Separation Date:
Previous Employer Hire Date:
REFERENCES
Reference #1: Character Reference whom you have known for at least three years. Please list Name, Address, Phone Number, and Occupation. References shall NOT be related to you or be past employers.
Reference #2: Character Reference whom you have known for at least three years. Please list Name, Address, Phone Number, and Occupation. References shall NOT be related to you or be past employers.
Reference #3: Character Reference whom you have known for at least three years. Please list Name, Address, Phone Number, and Occupation. References shall NOT be related to you or be past employers.
GENERAL INFORMATION
Have you ever been convicted of a criminal offense as an adult?:		Yes No
If yes, explain (give offense, sentence, and state):
Do you take or are you allergic to any medications?:		Yes No
If yes, List:
Have you ever used or tried illegal drugs?:		Yes No
If Yes, Disclose:
Have you ever been dismissed from employment or forced to resign, or have you ever resigned in order to avoid being dismissed?:		Yes No
If Yes, Describe:
Do you have any impairments, mental or physical, which would interfere with your ability to perform the work for which you are applying?:		Yes No
If Yes, Clarify:
Other Comments & Information:
WAIVER AND RELEASE
Electronic Signature of Applicant:
Date:
By signing my electronic signature above, I authorize the investigation of all statements made herein. I understand that any false statements or omissions of information requested are cause for rejection of my application. My signature on this application indicates that I am aware of the physically challenging demands for the Position of Firefighter or Medical Technician. I further authorize the Lineboro Volunteer Fire Department to contact my former employer(s) and listed references or other persons who can verify information, and I give my consent for former employer(s) and other contacted persons to respond to questions pertaining to information on this application.