Volunteer Application Step 1 of 4 25% Demographic InformationName* First Last Social Security #*D.O.B.* Driver's License #Email* Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Other PhoneAvailable From* : HH MM 24 HR FormatAvailable To* : HH MM 24 HR Format Experience & EmploymentDo you have any previous firefighting experience?*YesNoDepartment*From* To* Reason for leaving?*Any fire training?*YesNoList training*TrainingLocationYear Any medical training?*YesNoList training*TrainingLocationYear Do you have any physical limitations?*YesNoList limitations* Current Employer*Occupation*Have you ever received Workers' Compensation for an on the job injury?*YesNoExplain*Have you ever been convicted of a felony?*YesNoExplain* Emergency Contact InformationName* First Last Relationship*Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name* First Last Relationship*Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code By signing this application, I understand and agree to the following: Liberty Area Fire Protection Association may obtain information about you from a consumer reporting agency through (Shield Screening) for Liberty Volunteer Fire Department purposes. To submit to such physical examination as the Department may require either before or during my involvement with the Department. I hereby authorize the Department to obtain from my employer or any other affiliates, any information which may be needed to evaluate this application, unless stated otherwise. As a condition of my involvement with the Department, the Department may require any member to take polygraph exams, as the Department deems necessary, either prior to or during the course of my involvement. The Department has the obligation to maintain both a safe and productive work environment. Due to this, the Department reserves the right to request any or all firefighters to provide urine and/or blood samples for the purpose of detecting use of alcohol or illegal non-prescription drugs. I realize that the activities that I can expect to be involved in during my involvement with the Department are often hazardous and I agree to hold harmless the Department, its personnel , and all of its affiliates in the event that I should be injured while fulfilling the duties I may be assigned to or are expected to perform. Nothing in this application or any of the Department policies may be construed as a guarantee of permanent membership in the Department. I hereby certify that the foregoing statements are, to the best of my knowledge, true and correct; and I agree that any misstatement or omission as to the material fact in this application or personal interview will constitute grounds for unfavorable consideration of my application or discharge from further involvement with the Department. I agree to abide by all Department policies and procedures. Signature*Date* NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.
