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FREEBURG FIRE COMPANY #1

410 WEST HIGH STREET
FREEBURG, IL 62243
(618) 539-3288

Application for Membership as a Volunteer

First Name *

Middle Name *

Last Name *

Street *

per Date: Years

City *

State *

Zip Code *

Work Phone Number *

Home Phone Number

Other Phone Number

Date of Birth

Driver’s License #

Educational Background

Include any prior fire service training and/or education. (Use an additional piece of paper if necessary.)

High School

Years Completed /Dates Attended

Did You Graduate?

Yes
No

Degree, Major, or Type of Course

College

Years Completed /Dates Attended

Did You Graduate?

Yes
No

Degree, Major, or Type of Course

Graduate School

Years Completed /Dates Attended

Did You Graduate?

Yes
No

Degree, Major, or Type of Course

Trade, Business or Correspondence

Years Completed /Dates Attended

Did You Graduate?

Yes
No

Degree, Major, or Type of Course

Other

Years Completed /Dates Attended

Did You Graduate?

Yes
No

Degree, Major, or Type of Course

Military Experience

Were you in U.S. Armed Forces?

Yes
No

If yes, which service?

Dates of service: From:

Dates of service: To

Rank at Separation

Briefly describe your duties

General information

Are you legally authorized to work in the United States? *

Yes
No

Do you know of any reason why you cannot perform the essential functions of a firefighter with or without reasonable accommodations? *

Yes
No

Please describe any accommodations you believe would be required

Have you ever been convicted of, found guilty of, or pled guilty to any criminal offense?

Yes
No

Date:

Place:

Nature

(An affirmative answer will not automatically disqualify you from being considered as a candidate for employment.)

Membership in the Fire Company requires a significant time commitment. Training during the probationary period requires twenty hours per month. Active members are required to attend training at least four hours per month and a variable amount of time is required for emergency incident responses. Are you willing and able to make such a time commitment?

Yes
No

Person to be notified in case of emergency:

Name

Telephone:

Address:

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Employment History and Volunteer Service

List your present employer or most recent employer first. Include any fire service experience both volunteer and full-time, and non-employment community service and accomplishments. (You may use an additional piece of paper if necessary.)

May we contact your present employer? *

Yes
No

mployer Details

Employer

Employed

Supervisor’s Name

Address

From Mo/Yr.

Supervisor’s Phone Number

City

To Mo/Yr. (copy)

Your Job Title

State

Reason for Leaving

Duties

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Certification of Applicant

The statements that I have made in this application are true and complete to the best of my knowledge and I understand that any alteration or concealment of a material fact will result in my disqualification before appointment or dismissal after appointment. I hereby authorize Freeburg Fire Company #1 and its representatives to investigate my background, including but not limited to past employment, medical history and records, and military and police records. My permission is hereby given to any and all persons, agencies, corporations, firms, or associations to release any and all such information, records or other documents to Freeburg Fire Company #1 or its presentatives for its inspection and copying. A copy hereof shall be considered as authentic as the original.

Date *

Signature of Applican *

Clear Signature

For Additional Information:

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Email *

Proudly serving Freeburg and the surrounding community with dedicated fire protection, rescue response, and public safety services.

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About
Public info
Members
Join
Contact

About
Public info
Members
Join
Contact

CONTACT US

ADDRESS

410 W High St, Freeburg, IL 62243

CALL

(618)539-3288

E-MAIL

mail@freeburgfire.com

Emergency Dial 9-1-1

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