LTVFD Application

APPLICATION

PLEASE PRINT OUT APPLICATION AND ANSWER ALL QUESTIONS.
APPLICATION MUST BE DELIVERED TO LTVFD STATION ONE
PLEASE CONTACT US FOR AN APPOINTMENT.

APPLICATION FOR FIREFIGHTER

NAME-LAST___________________________________FIRST________________________________M.I._____

HOME ADDRESS:_____________________________________________________________________________

CITY___________________________________STATE___________________________ZIP_________________:

PHONE-HOME___________________CELL___________________OTHER______________________________

SOCIAL SECURITY NUMBER:__________________________DATE of BIRTH_______/_______/___________

EMERGENCY CONTACT NAME:_______________________________________________________________

RELATIONSHIP____________________________PHONE_____________________________:

ANY KNOWN ALLERGIES?__________EXPLAIN__________________________________________________

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MEDICAL PROBLEMS?_______________________________________________________________________

PLEASE LIST TIMES YOU WOULD BE AVAILABLE TO ANSWER ALARMS:___________________________

HAVE YOU APPLIED TO LTVFD IN THE PAST?_________________DATE if YES________________________

HAVE YOU BEEN A MEMBER OF ANOTHER FIRE DEPARTMENT?__________________________________

HAVE YOU HAD FIRE OR EMS EXPERIENCE OR TRAINING? IF YES, EXPLAIN_______________________

DO YOU HAVE OTHER SPECIALIZED TRAINING?_________________________________________________

WHAT TYPE OF DRIVERS LICENSE DO YOU HOLD?______________________________________________

LICENSE NUMBER______________________________EXP. DATE_______/_______/_______________

HAS YOUR LICENSE EVER BEEN SUSPENDED, REVOKED OR TERMINATED?__________________

IF YES, PLEASE EXPLAIN_____________________________________________________________________:

EDUCATION:____________

HIGHEST GRADE COMPLETED_____________________________________

NAMES OF HIGH SCHOOL(S), VOCATIONAL SCHOOL(S), COLLEGE(S) ATTENDED:

MILITARY SERVICE:

HAVE YOU SERVED ON ACTIVE DUTY IN THE MILITARY (INCLUDE INITIAL ACTIVE DUTY IN
NATIONAL GUARD OR RESERVES)?_________________________

BRANCH______________________________________________________________:

YEARS SERVED:______/______/____________TO______/______/____________

HIGHEST RANK ATTAINED:__________________________________________________________________

PLEASE LIST ANY TRAINING, EDUCATION, SKILLS, HOBBIES, VOLUNTEER WORK OR OTHER
INFORMATION YOU FEEL MAY BE HELPFUL IN EVALUATING YOUR
APPLICATION:_______________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
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IN YOUR OWN WORDS, PLEASE TELL WHY YOU WISH TO BECOME A MEMBER OF LAFAYETTE
TOWNSHIP VOLUNTEER FIRE
DEPARTMENT:_______________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

I UNDERSTAND I AM REQUIRED TO ATTEND A MINIMUM OF TWO HOURS OF TRAINING PER
EVERY TWO MONTHS REQUIRED BY THE STATE OF INDIANA. THIS REQUIREMENT DOES NOT
APPLY TO INITIAL RECRUIT TRAINING. TRAINING WILL BE PROVIDED BY THE DEPARTMENT.

SIGNATURE____________________________________________________________________________

DATE: if YES_______/_______/______________

I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE, ACCURATE
AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE INVESTIGATION OF ALL
STATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THAT ANY
MISREPRESENTATIONS OR FALSIFICATIONS OF INFORMATION PROVIDED MAY LEAD TO
WITHDRAWAL OF OPPORTUNITY OR TERMINATION FOLLOWING MEMBERSHIP.

DATE:____________________________________________

I AGREE THAT IF MY APPLICATION FOR MEMBERSHIP IS ACCEPTED AND APPROVED I WILL
BE HELD PERSONALLY RESPONSIBLE FOR ANY AND ALL DEPARTMENT ISSUED EQUIPMENT
AND SUPPLIES. FURTHER, I AGREE TO RETURN ALL DEPARTMENT ISSUED EQUIPMENT AND
SUPPLIES UPON LEAVING OR BEING TERMINATED FROM THE DEPARTMENT.

I UNDERSTAND THAT IF MY APPLICATION IS APPROVED THERE WILL BE A SIX-MONTH
PROBATIONARY PERIOD, AND, IF MY PERFORMANCE IS NOT AS EXPECTED BY THE
DEPARTMENT WITHIN THAT PERIOD I MAY BE DISCHARGED THROUGH A VOTE, OR BY
SECRET BALLOT VOTE OF THE GRIEVANCE COMMITTEE AND OFFICERS OF THE
DEPARTMENT, WITHOUT RECOURSE.

I UNDERSTAND THAT I WILL BE REQUIRED TO ATTEND ANY TRAINING OFFERED BY THE
DEPARTMENT, FUNDRAISING ACTIVITIES AND OTHER DEPARTMENT FUNCTIONS THAT I AM
AVAILABLE FOR.

HAVE YOU EVER BEEN CHARGED WITH OR CONVICTED OF A FELONY OFFENSE?_______________
IF YES, PLEASE
EXPLAIN:____________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
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I AGREE TO A CRIMINAL BACKGROUND CHECK AS A CONDITION OF APPLICATION TO
LAFAYETTE TOWNSHIP VOLUNTEER FIRE DEPARTMENT.

PLEASE NOTE:
If you are under 18 years of age and applying for consideration as a Junior Firefighter parental permission in writing must
be on file with the Department before your application will be accepted. We do not accept applications for Junior
Firefighters from those under 16 years of age.
Please Contact Us for more information on the Junior Firefighter Program.

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