| Position Applying For: |
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Fire Crew
Fire Police
Support Member
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| General Information |
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Full Name:
Last, First, Middle Name
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| Social Security Number:
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| Birth Date:
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| Drivers License Number:
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| State of License:
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Address:
Street Address, City, State / Province, Zip Code
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| E-mail Address:
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| Phone Number:
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| Alternate Phone Number:
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| Current Employer:
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Employer Info (Current):
Name, Address Phone Number
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| Can you leave work for Fire Calls: |
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No
Yes
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| Name of Supervisor:
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| Normal Work Schedule:
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| Emergency Contact Name:
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| Emergency Contact Phone Number:
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| Education History |
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| Do you have either a High School Diploma or GED: |
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No
yes
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School or Training:
Please include any colleges or any other schools attended.
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Special Qualifications:
Licenses, skills with machines, other Fire Department memberships or related archives
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| Work History |
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| 1. Name of Employer:
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| 1. Address:
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| 1. Supervisor Phone Number:
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| 1. Job / Duties Performed:
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| 1. Reason for Leaving:
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| 2. Name of Employer:
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| 2. Address:
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| 2. Supervisor Phone Number:
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| 2. Job / Duties Performed:
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| 2. Reason for Leaving:
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| 3. Name of Employer:
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| 3. Address:
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| 3. Supervisor Phone Number:
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| 3. Job / Duties Performed:
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| 3. Reason for Leaving:
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| Prior Residences |
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Address 1:
Street Address, City, State / Province, Zip Code
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Address 2:
Street Address, City, State / Province, Zip Code
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Address 3:
Street Address, City, State / Province, Zip Code
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| References |
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| Please list three persons who are not related to you and who have definite knowledge of your qualifications or fitness for membership. Do not use names of supervisors you listed above as we consider them references, unless otherwise noted. |
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| 1. Full Name:
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| 1. Phone Number:
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| 2. Full Name:
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| 2. Phone Number:
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| 3. Full Name:
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| 3. Phone Number:
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| Criminal History |
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| Have you ever been convicted of a crime? Please include any misdemeanor or felony convictions: |
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No
Yes
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| If yes, list date of offense, all charges for which you were convicted and the disposition:
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| Medications |
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| Do you have any medical conditions or medications that would prevent you from your duties for the position you are applying for: |
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No
Yes
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| Authorization for Release of Information |
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| Enter your full name which signifies your understanding and approval of the above statement:
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| Submitted on :
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10/14/2024 0404 |
| Resume / File Upload:
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I authorize the Hersey Volunteer Fire Company to conduct an investigation into my background, including but not limited to anyrecord of Criminal Arrests which may exist, and to the release to the Hershey Volunteer Fire Companyany and all information obtained as a result of such investigation.
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I further understand that this investigation will be confidential and findings contrary to theinformation provided on the application may subject me to prosecution under the Pennsylvania crimescode for unsworn falsifications (18 PA. C.S. §4904). I understand that the information will be released tothe appropriate officers of the Hershey Volunteer Fire Company when the investigation is completed.
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I verify that the information setforth in this application is true and correct. I understand that any falsification contained in this application shallresult in denial or termination of membership. This verification is made subject to the penalties ofsection 4904 of the crimes code of Pennsylvania(18 PA. C.S. §4904) Relating to unsworn falsifications.
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