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Your Full Name (Last, First, Middle): *
Your Address: *
provide Expiration to
City *
State: * --- Select Choice --- AL AK AR AZ CA CO CT CZ DC DE FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Choice 58
Zip Code: *
Permanent Address:
Permanent City:
Permanent State: AL AK AR AZ CA CO CT CZ DC DE FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Choice 58
Permanent Zip Code:
Permanent County:
Telephone (Current Home):
Telephone (Current Cell Phone): *
Age 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Social Security Number: *
Driver's License Number: *
Driver's License State: * Driver's License State: AL AK AR AZ CA CO CT CZ DC DE FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Choice 58
Driver's License Expiration Date: *
High School Attended (Please indicate highest grade completed):
College Attended / College Currently Enrolled:
Degree / Educational Concentration:
Health Information: Do you have any health / physical conditions that would interfere with you providing emergency service? Yes (please fill out next question) No (Please skip next question)
Please describe any health or physical conditions that would interfere with providing emergency services:
Please provide your family physician's name and phone number.
Are you taking any medications on regular basis? If so, please provide a list.
Name and Location of the Fire Company / Department?
Chief's Name and Phone Number:
If yes to question above, please list the date and explain action.
List Any Experience (Bring any/all certifications to interview):
Emergency Contact (Please provide Name and Best Method of contact):
Background and Criminal History
Please include all summaries, misdemeanors, felonies, and traffic history:
I authorize the Loyalsock Volunteer Fire Company to perform any additional criminal background check on my behalf and understand it is my responsibility to complete such forms to include the same information regarding my past criminal history as a requirement for the Live-In Program. In addition, I authorize Loyalsock Volunteer Fire Company to contact my list of references provided as part of my character makeup prior to and following Live-In Program application and interview review. Yes No
I authorize the Loyalsock Volunteer Fire Company to contact my list of references provided as part of my character, morals, state of mental and physical health, training recorded, and certifications prior to and following Live-In Program application and interview review. Yes No
List 3 People (including Name, Phone, and Address) not related to you that have known you for more than 3 years:
I wish to participate in Loyalsock Volunteer Fire Company No.1 (LVFC) Live-In Program. I understand that I will be contacted for an interview and that the Live-In Program Committee will make the final decision to accept or reject my application. I further understand that, if accepted into the Live-In Program, I will abide and adhere to the LVFC Trustees Manual, Current SOP/SOGs, Company By-Laws, Constitution, and New Member Handbook. In addition to the duties of emergency services, I understand that I will be expected to read, understand, and adhere to the Live-In Program Guidelines, Rules, and Regulations. If I fail to meet these expectations, I may be dismissed from the Live-In Program. * --- Select Choice --- Yes No
I hereby acknowledge all information filled out in the above sections to be correct and fully accurate. Any failed or false information will be documented and open to disclosure during interview process. If you accept the terms and conditions, please digitally type in your full name and click submit below.
