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ONLINE APPLICATION APPLICANT INFORMATION   First Name:  Middle Name:  Last Name:    Social Security Number:  Driver's Liscence Number:    Address:  Apt. # (if applicable):  City:  State:  Zip Code:  Please List All   Previous Addresses:    Home Phone:  Work Phone:  Cell Phone:    E-Mail Address:    Sex:  Date of Birth:  Are You a U.S. Citizen:    YES    -or-    NO Place of Birth:  Marital Status:  Name of Spouse (if applicable):  Please List the Names and   Ages of All Dependent Children:      Please List at least 3 references. These references must be people who are familiar with your personal capabilities and/or character. Please include the name, full address, and phone number of each reference. (NO RELATIVES PLEASE) WORK HISTORY (Please list in order starting with most recent)     EMPLOYER #1 Employer:  Employment Dates:    From:  To: Job Title:  Employer Phone:  Employer Address:  Employer State & Zip:  Reason For Leaving:      EMPLOYER #2 Employer:  Employment Dates:    From:  To: Job Title:  Employer Phone:  Employer Address:  Employer State & Zip:  Reason For Leaving:      EMPLOYER #3 Employer:  Employment Dates:    From:  To: Job Title:  Employer Phone:  Employer Address:  Employer State & Zip:  Reason For Leaving:    EDUCATION & SPECIAL TRAINING   Please list all of your previous education including Elementary School, High School, College/Vocational, and any relative special training or previous pertinant experience.   PERSONAL BACKGROUND   Have you ever belonged    to another fire company,   first aid, or rescue squad?:    YES    -or-    NO IF SO, please list names and dates of service:    As a member, you will be required to attend fire school within one year of joining. Are you able to attend?:    YES    -or-    NO   Do you have any relatives or close friends who are currently members of the Bellmawr Fire Department?:    YES    -or-    NO IF SO, please list all names of friends or relatives who are current members of the BFD:    Have you ever served in the U.S. Military?:    YES    -or-    NO     Do you have any mental and/or physical impairment which may limit your ability to perform the duties of a firefighter?:    YES    -or-    NO IF YES, please explain:      Do you have any chronic ailments, handicaps, or infectious disease(s)?:    YES    -or-    NO IF YES, please explain:      Please list, IF ANY, all major accidents and/or points on your Driver's License:      Has your Driver's License ever been revoked and/or suspended?:    YES    -or-    NO IF YES, please explain:    Have you ever been convicted of any crime?:    YES    -or-    NO IF YES, please explain:  EMERGENCY CONTACTS     EMERGENCY CONTACT #1 Name:  Phone:  Address:  City, State, & Zip:  Relationship:      EMERGENCY CONTACT #2 Name:  Phone:  Address:  City, State, & Zip:  Relationship:    REASON FOR WANTING TO JOIN   What is your reason for wanting to join the Bellmawr Fire Department? (In this box you can also add any general comments you wish to add.)   AUTHORIZATION TO RELEASE INFORMATION   PLEASE, CAREFULLY READ, EVERYTHING IN THE FOLLOWING TEXT BOX. THE BOX BELOW CONTAINS INPORTANT INFORMATION THAT YOU MUST AGREE TO IN ORDER TO SUBMIT YOUR APPLICATION. I certify that the statements and answers in this document are true and accurate to the best of my knowledge and that I have not knowingly provided incorrect information or withheld information that would misrepresent the facts. I further understand and agree that any false statements made by me may be considered sufficient reason for denial of this application, or may result in my dismissal if accepted for membership. I hereby authorize release of any information regarding military, employment, medical, state, and/or local police records to the Bellmawr Fire Department, to investigate the information contained herein. I further agree to submit to a physical examination and to be tested, as part of this examination, for drug, alcohol, and infectious diseases. I further waive any right to privacy I may have, in connection with the information supplied in this application, and release the Borough of Bellmawr, and the Bellmawr Fire Department, from any claim or liability whatsoever, arising from receipt and use of such information as contemplated herein. I hereby request and authorize the disclosure of, and agree to furnish and/or provide, any records, reports, or copies, of any information regarding or related to any previous military service, fire department service, police service, and/or service for EMS, to the Bellmawr Fire Department. I further authorize the Bellmawr Fire Department to inspect and/or make copies or abstracts of these documents. I hereby request and authorize the disclosure of, and agree to furnish and/or provide, any records, reports, or copies, of any information regarding or related to any previous or future medical or psychiatric treatment, examination, consultation, or confinement, to the Bellmawr Fire Department. I further authorize the Bellmawr Fire Department to inspect and/or make copies or abstracts of these documents. I hereby request and authorize the disclosure of, and agree to furnish and/or provide, any records, reports, or copies, of any information regarding or related to any previous or future employment, to the Bellmawr Fire Department. I further authorize the Bellmawr Fire Department to inspect and/or make copies or abstracts of these documents. I hereby request and authorize the disclosure of, and agree to furnish and/or provide, any records, reports, or copies, of any information regarding or related to any previous or future criminal convictions, to the Bellmawr Fire Department. I further authorize the Bellmawr Fire Department to inspect and/or make copies or abstracts of these documents. I fully understand that the Bellmawr Fire Department will investigate all of the information that I have authorized the Bellmawr Fire Department to access, and may also effect the Bellmawr Fire Department's decision to accept my application. I fully read, agree to, and understand everything stated above.    I fully read, agree to, and understand everything stated above in the text box. I further agree to all of the authorizations to the release of information. SUBMIT APPLICATION   Please review all of the information you supplied. We will review your application and we will contact you within two weeks. Please allow us ample time to review your application. If two weeks passes and you are not contacted by the Bellmawr Fire Department, you may then attempt to contact us. We cannot gaurentee that your application will be accepted nor denied within two weeks, it may take longer depending on further findings or review. We would like to thank you for expressing your interest in joining the Bellmawr Fire Department! After you carefully review all of the information you supplied, feel free to click the "Submit My Application" button below to submit your information to the Bellmawr Fire Department.   Back Home

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