Date Submitted:
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02/18/2025 1136 |
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Contact Information |
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First Name:
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Last Name:
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Date of Birth:
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Sex: |
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Male
Female
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Phone #:
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Email Address:
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Current Address |
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Street Address:
eg. 29 E 5th Avenue
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City:
Eg. Collegeville, Trappe, Royersford, Perkiomen
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State:
Eg. PA, MD, DE,NJ
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Zip Code:
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Years at Current Address:
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Previous Address Information |
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Previous Address :
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Years at Previous Address:
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Driver License Information |
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Driver's License Number:
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Class of Driver's License:
Please check all that Apply
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A-CDL
B-CDL
C
M
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Copy of License:
Please attach a copy of your license
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Has your driver's license ever been suspended?:
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If your license HAS been suspended please explain the circumstances.:
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Employment Information |
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Employment Status: |
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Employed
Un-Employed
Retired
Self-Employed
Disability
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Occupation & Employer Information:
Include Address; phone numbers and years employed
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Previous Employers:
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References (3):
Please list Names & Phone Numbers and
Email addresses
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Tell us about you |
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Community Activities:
Lions Club, Scouts etc.
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Have you ever been convicted of a crime?: |
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Yes
No
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If you HAVE been convicted of a crime please describe the circumstances.:
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Do you Physical Limitations that would prevent you from performing Firefighting duties: |
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Yes
No
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If Yes Explain Physical Limitations:
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Prior Training |
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Prior Firefighter Training?: |
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Yes
No
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Prior Training-Type:
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None
Firefighter I
Firefighter II
Hazardous Materials Operations
Vehicle Rescue Technician
Water Rescue Awareness
Water Rescue Operations
Current First Aid, CPR & AED
Infectious Control, Bloodborne Pathogens
Pump Operations
Emergency Vehicle Operators Course
NIMS 100
NIMS 700
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Upload Certifications:
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Current or Past Membership(s):
Are you a current or past member of another Fire / Ambulance / Rescue Department. (If yes explain & include references.)
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Any other training or experience?:
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Membership Type |
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What type of membership are you applying for?: |
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Active 18+ years
Junior Firefighter - 16/17 years
Fire Police + 18 years
Contributing
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Junior Firefighters:
Please attach working papers with this application. All Jr firefighter applicants and parents must meet with the Fire Chief
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Emergency Contact Information. |
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Name(s):
List Name or Names
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Address(s):
List in same order as names
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Cell Phone #'s:
List in same order as Names
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Home Phone #:
List in same order as Names if available. If none, use XXX-XXX-XXXX
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Email Address(s) Of Emergency Contact:
List in same order as Name(s) If none available, use XXXXXXXXXXX
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How did you hear about us:
Check all that apply
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County Recruitment Program
Email
Friend
Member
Recruitment Flier
School Guidance Counselor
Social Media
State Recruitment Program
N/A
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Investigation Authorization
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Child Abuse Clearence:
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Approve Investigation/Background Check:
By clicking yes to the approve Investigation/background check, you authorize the appointed members of the Collegeville Fire Company No. 1, to invistigate all information contained within this application. This investigation will include a criminal history check, drivers license record check with any appropriate authority. And that you understand that this application my be reviewed any time, and that falsification of information my be grounds for disciplinary action, including and up to termination from the Collegville Fire Company No. 1
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Attach these two forms below:
PA Criminal History Background Check:
Child Abuse Clearance. Links Below. |
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PA Criminal Background Check:
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Pa Criminal Background Check
Child Abuse Clearence History Clearence Check
By clicking yes to the approve Investigation/background check, you authorize the appointed members of the Collegeville Fire Company No. 1, to invistigate all information contained within this application. This investigation will include a criminal history check, drivers license record check with any appropriate authority. And that you understand that this application my be reviewed any time, and that falsification of information my be grounds for disciplinary action, including and up to termination from the Collegville Fire Company No. 1
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