Volunteer - Limestone Fire Department

Application Form
For
Volunteer TODAY

Have you ever used another name?

Yes No

If yes, please explain?

Have you ever worked for this company?

Yes No

Have you ever been convicted of a felony?

Yes No

If yes, explain:

References

Please list three professional references.

Previous Employment

Most recent or current employer

Date

May we contact your previous supervisor for a reference?

Yes No

Previous employer (if less than 2 years)

Date

May we contact your previous supervisor for a reference?

Yes No

Emergency Services Experience Information

Have, or are, you a member of ANY Fire, Rescue, or EMS Department?

Yes No

Dates of service

Please List any Certifications and Their Expiration Dates

Cert	Exp Date

Interest in our Department

Please briefly state why you are interested in joining the LFD. Please state what aspects of Emergency Services you’re interested in and how you plan to participate.

How did you hear about Limestone? Community Website LFD Member Other

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Schedule and Availability

Joining a professional organization such as Limestone Fire Department requires a significant commitment of personal time. This decision should take into account commitments and priorities that you already have established, such as school, work, and family obligations. Consider that initial training as an Emergency Responder (EMR) requires 60 hours and EMT-Basic requires 120 hours. These classes typically meet twice a week at either Limestone Central, AMT, or the EMS office. These classes last up to 4 months, including weekends.

Given your current schedule/obligations, please complete the below chart, indicating your current availability for training and participation in activities at Limestone Fire Department.

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
0600-noon
Noon-1800
1800-midnight
Midnight-0600
*Please complete using: U (unavailable), S (sometimes available), A (available)

*The Distance from my house to the nearest Limestone Fire Department Station (road miles)

Background Check Authorization

Limestone Township Fire Protection District

Authorization of Background Check

Applicant Consent

I, the undersigned, understand and agree the LIMESTONE TOWNSHIP FIRE PROTECTION DISTRICT will verify all or part of the information I have given. I understand that this verification may include an inquiry into my driving record, criminal and civil records, prior employment, education, as well as any information provided above. I understand that I will be required to consent to a physical and drug screen. If accepted, this authorization shall remain on file and shall serve as an ongoing authorization for any of the above reports, at any time, during my tenure on the department. I authorize the release of such information as may be necessary to verify any information I have provided. I release, and hold harmless from all liability, any individual or entity requesting, or supplying, information with respect to this application.

Thank You! Your request successfully sent.

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Contact

309-697-4312
7800 W. Plank Rd. Peoria, IL 61604

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