Application
For
Union Road Volunteer
Fire Department
Last Name _________________ First Name____________
Middle Name ______________ Date: _______________
I. Personal Data
Address______________________________________________________________
Street and Apartment Number City State Zip
Home Telephone_________________ Work Telephone ____________________
Cell Number ____________________ Date of Birth _____/______/_______
Social Security # ________-_____-________ Drivers License # & State _____________
Are you a United States Citizen? Yes _____ No ______
If no, are you eligible for employment in the United States?
Do any of your relatives work for us? Yes _____ No ____
If yes, list the names and relationship: _______________________________________________________________________
______________________________________________________________________
Have you served in the U.S. Armed Forces? Yes ____ No ____
If yes, Branch _______________ Dates ________ to _________
Highest Rank Attained _______________ Occupational specialty _______________________________________________________________
Have you ever been convicted of a crime other than a minor traffic violation? (Does not automatically disqualify you.) Yes ______ No _____ If yes, list date, place and disposition of case: _______________________________________________________
Education Information
Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 / GED /
College 1 2 3 4 / Graduate school 1 2 3 4
Schools Name & Location Dates Attended Graduate Degree Major_
High School_____________________________________________________
College or
University_______________________________________________________
Graduate or
Professional_____________________________________________________
Business
Trade or
Military_________________________________________________________
EMPLOYMENT HISTORY
List below your previous work experience. Start with your most recent position and back in time. Please include service in the U.S. Armed Forces and any self employment. Use continuation sheet if more space is needed.
LAST OR CURRENT JOB
Employer ___________________________________ Phone # ____________
Employers Address _______________________________________________
Your Title ______________________ Number of people supervised ________
Specific Duties ___________________________________________________
_______________________________________________________________
We will contact references: ________________________________________
Reason for leaving: _______________________________________________
NEXT MOST RECENT JOB
Employer ___________________________________ Phone # ____________
Employers Address _______________________________________________
Your Title ______________________ Number of people supervised ________
Specific Duties ___________________________________________________
_______________________________________________________________
We will contact references: ________________________________________
Reason for leaving: _______________________________________________
NEXT MOST RECENT JOB
Employer ___________________________________ Phone # ____________
Employers Address _______________________________________________
Your Title ______________________ Number of people supervised ________
Specific Duties ___________________________________________________
_______________________________________________________________
We will contact references: ________________________________________
Reason for leaving: _______________________________________________
Personal References (List three people, other than relatives or former employers, who can vouch for your character.)
Name Address City/State Number Years Known
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
CERTIFICATION AND CONSENT
A) A criminal background check to be supplied by applicant.
(Gaston County Sheriff’s Office)
B. A driver’s license background must be supplied by applicant.
(North Carolina DMV)
C. A drug test must be taken and results submitted to department
(See Chief Officer for time and date.)
D. If you are from out of state then information above must come from home state as well as NC.
FIREFIGHTING EXPERIENCE
List any firefighting related experience that you have, including department and chief’s name and phone number.
I voluntarily give the Union Road Volunteer Fire Department permission to confirm by personal inquiry, or otherwise, information provided in this application. I release from all liability or responsibility Union Road Volunteer Fire Department and all persons, companies or corporations providing information to the department about me.
Applicants Signature__________________________________Date________
DEPARTMENT USE ONLY
Review Board
Members (Print)
Chief Officer ____________________________________________
Captain ________________________________________________
Firefighter ______________________________________________
Comments and Recommendations
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Date submitted to chief ________________________________
Review Board Signatures and Date
Chief __________________________________________________
Captain ________________________________________________
Firefighter ______________________________________________