Fire Department Acknowledgement Response

2. 
3. Volunteer Firefighter Application

   Cecil Township Volunteer Fire Department Inc. 

5. Membership Type*

   1. Active
   2. Associate
   3. Junior
   4. Life Active
   5. Life Non Active
9. First Name*
10. Middle Name
11. Last Name*
13. Age*
14. Date of Birth*
    Date of Birth
16. Do you have a Drivers License?*

    1. Yes
    2. No
17. Class*
    -- Select One --N/AClass AClass BClass C
18. Expiration Date*
    Expiration Date
20. Address*
21. PO BOX
23. City*
24. State*
25. Zip Code*
26. Apartment #
28. Home Phone*
29. Cell Phone*
30. E-Mail*
32. Marital Status
33. Spouse Name
35. Beneficiary
36. Relationship
38. IF AT ABOVE ADDRESS LESS THAN FIVE YEARS, LIST PREVIOUS ADDRESS
40. Address
42. City
43. State
44. Zip Code
48. EDUCATION
50. High School Graduated From*
51. Year
53. Further Education
57. EMPLOYMENT
59. Present or Most Recent Employer*
61. Occupation*
62. Phone*
66. Previous or Existing Fire Dept. Memberships
67. Have you ever been a member of a fire department in Cecil Township?*

    1. Yes
    2. No
69. Check any stations you are a member or previously had membership at

    1. Lawrence (Cecil Twp. Volunteer Fire Company No.1)
    2. Muse (Cecil Twp. Volunteer Fire Company No.2)
    3. Cecil (Cecil Twp. Volunteer Fire Company No.3)

    Check all that apply

70. Most Current Membership*
    -- Select One --Lawrence (Cecil Twp. Volunteer Fire Company No.1)Muse (Cecil Twp. Volunteer Fire Company No.2)Cecil (Cecil Twp. Volunteer Fire Company No.3)
72. Membership Status*
    -- Select One --InactiveActiveSocialAssociateLife ActiveLife Non ActiveJunior

    If you have not had any participation in the last 6 months of completing this application. Select Inactive or Life Non Active.

74. Original Date of Membership in Cecil Township*
    Original Date of Membership in Cecil Township

    When you began serving in Cecil Township

75. Years of Service Total*
77. Provide a brief explanation of your membership*

    Include explanation of changes in station memberships and positions/ offices held during your membership. 

79. Have you ever been a member of a fire department outside of Cecil Township?

    1. Yes
    2. No
81. Fire Department*

    Most recent membership

83. Address*
85. City*
86. State*
87. Zip Code*
89. Chiefs Name*
90. Chiefs Phone Number*
92. Brief description of fire department memberships

    Provide memberships of any other fire departments and chiefs contact information. 

    Provide details of your roles, and any offices held during your membership

94. Are you currently still a member?*

    1. Yes
    2. No
96. Reason for leaving*
98. Certifications and Licences*

    1. Essentials
    2. Hazardous Materials Awareness
    3. Hazardous Materials Operations
    4. Hazardous Materials Tech.
    5. NIMS 100
    6. NIMS 200
    7. NIMS 700
    8. NIMS 800
    9. Firefighter I
    10. Firefighter II
    11. Vehicle Rescue Tech
    12. CPR First Aid & AED
    13. EMR
    14. EMT
    15. A-EMT
    16. Paramedic

    Check any that apply

    These are the basic certifications we look for on the application. You can provide more details below.

100. Additional Certifications, Training & Education *

     List any additional supporting qualifications here

104. History
106. Have you ever been arrested and/or convicted of a crime?*

     1. Yes
     2. No
108. Explain*
110. Have you had a serious injury or illness in the previous five years?*

     1. Yes
     2. No
112. Explain*
114. Have you ever received compensation for injuries? *

     1. Yes
     2. No
118. References

     Provide three (3) references with exceptions of family and members of any Cecil Township Fire Department.

120. Reference 1
124. Name*
125. Email Address
127. Address
129. City*
130. State
131. Zip Code
133. Phone Number*
134. Fax Number
136. Reference 2
140. Name*
141. Email Address
143. Address
145. City*
146. State
147. Zip Code
149. Phone Number*
150. Fax Number
152. Reference 3
156. Name*
157. Email Address
159. Address
161. City*
162. State
163. Zip Code
165. Phone Number*
166. Fax Number
170. Agreement

     1. This application is true and complete to the best of my knowledge.  You are hereby authorized to make any investigation of my personal history.  I understand that if I am accepted to this organization, falsified statements on this application shall be sufficient cause for my dismissal.

     2. Applicant agrees to serve a minimum of 1 year or can be held financially responsible for any pre-memebrship cost.

172. Applicant Signature*

     By typing your name above, you agree to the terms of this application.

173. Date*
     Date
175. Parent/ Guardian Name*
176. Relationship*
178. Phone Number*
180. Pennsylvania State Police Criminal Record Check

     1. I acknowledge that Cecil Township will perform a PA State Police background check using the information provided in this application.

182. Initial*

     By typing your initials above, you agree to the terms of this application.

183. Date*
     Date
Leave This Blank:


187. 1. Receive an email copy of this form.
188. Email address

     This field is not part of the form submission.

189. Submit Submit and Print

* indicates a required field