Submit Your Application Although this form is available on a smartphone, we recommend filling it out on a computer for the best experience and to avoid any issues with internet connectivity disrupting your application submission process. Butler Volunteer Fire Department Which Position are applying for?Full TimeFirefighterMPOEMT Personal Information Date Last Name Middle Name First Name Address City State Zip Home Phone Cell Phone Date of Birth Place of Birth Email Address Valid Car InsuranceYesNo Valid Driver LicenseYesNo Have you ever filled out an application with us before?YesNo If yes, give approximate date Have you ever been employed with us before?YesNo If yes, give approximate date Have you ever been bonded?YesNo If yes, indicate reason May we contact your present employer?YesNo Are you 18 years of age or older?YesNo Can you provide proof of eligibility for employment in the United States?YesNo Education High School Attended Location Did you graduate? Year College Attended Location Did you graduate? Major Year(s) attended Degree/Diploma/Total Credits College Attended Location Did you graduate? Major Year(s) attended Degree/Diploma/Total Credits College Attended Location Did you graduate? Major Year(s) attended Degree/Diploma/Total Credits Special Skills Other Education Information Firefighter I Firefighter II Driver Operator Pumper Aerial Fire Officer I Fire Instructor EMT-Basic EMT-IV Tech EMT-Intermediate EMT-Paramedic List any computer skills you possess, i.e. hardware, software, programming skills etc.. Other Fire Services Training List any other special skills or certifications. Wisconsin EMT Number NREMT# Fire Service Certification Number List proficiencies with any heacy equipment, industrial equipment, or specialized training: Military Employment Please give accurate, complete, full-‐time and part-‐time employment history including military service. Start with your most recent employer FIRST. If self-employed, give firm name and business references. If necessary, attach additional sheets using the same format. Company Name Address City State Zip Phone Name of Supervisor Employed (Month and Year)From - To Job Title and Description Reason for Leaving Add other Employeer Criminal History Have you ever been convicted of any law violation in the last ten years or any pending convictions, including traffic violations?YesNo If yes, list convictions and pending also all traffic offenses: Date Location Violation Dispostion References Please list three persons who have knowledge of your experience and qulifications for this position, preferably current or previous supervisors, co-workers, instructors, etc.. Do not inclued relatives. If you are know to your references by another name, please note. Name Relationship Address Telephone City State Zip Years Acquainted Add another Reference Other Information Is there any reason that your present health condition would restrict you from your activities as a firefighter, first responder, driver/operator or emergency medical service provider?YesNo If yes, explain: Do you suffer from any fear/phobias that would restrict your activities as a firefighter, first responder, driver/operator or emergency medical service provider?YesNo If yes, please explain: Emergency Contact Name Address City State Relationship Zip Add additonal Emergency Contact I agree that all informaion provide is accurate and to all questions asked of me. And that I have no NO Felony Convictions or pending Convictions and that Butler Volunteer Fire Department can run backgroud checks and driving record checks.YesNo I agree to permit the Butler Volunteer Fire Dpartment, Inc. to conduct an investigation into my background through the police department, state law enforcement organizatinos, FBI, or any other recongnized law enforcement organization. The Butler Volunteer Fire Departmnet, Inc. will hold this information in confidence. Need assistance with this form? Report abuse
