Apply Online | North Park Fire Protection District

Name *

First

Middle

Last

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Station

Start Date

Drivers License #

Class

Marital Status

Name of Spouse

First

Last

Your Age

Your Date of Birth

High School Graduation Date

GED Completed

Your Occupation

Employer

Employers Phone

Address of Employer

Address Line 1

Address Line 2

City

State

Zip Code

Work Hours

Days of the week normally worked

Years

PREVIOUS FIRE DEPARTMENT HISTORY:

Please list any fire departments you have been affiliated with, along with your dates of service.

I understand, consent and agree that my current and former employers may be contacted by the Fire District for verification of my employment history and references. If, for any reason whatsoever, you object to the Fire District contacting such current or past employers so state your objection and give the reason therefore.

I do not object
I do object for the following reason

Reason

Hobbies or other regular activities which can be expected to keep you away from home on a regular basis; explain:

Eyes

Hair

Height

Weight

Vision

General Physical Condition; Explain:

List any permanent or current medical or physical conditions, disabilities, chronic conditions or limitations, if any, that you know of that would limit or affect your physical involvement and participation as a volunteer firefighter; be specific:

If currently under a physician's care, list name and address of physician, date last seen and reason for treatment; be specific:

Regular Physician's Name

Address

Phone #

Blood Type

Restrictions on use of blood transfusions or other medical procedures, if any:

Allergies

Permanent or current medications, if any:

Names, address, phone number and relationship of person to be notified in case of personal emergency:

List any specific special interest, qualifications, training or abilities which you currently possess which you believe will be useful to you and the Fire District in the fire service; be specific as to course, training, certificates and experience:

I certify to the Fire District that I currently hold a valid Illinois Driver's License #

Driver's License classification of

I further certify my driving privileges are not currently suspended or revoked or scheduled to be suspended or revoked.

Yes
No

List three (3) personal references by full name, address and phone number describing your relationship with each person named. Do not use members of your family.

I certify that I have not been convicted of any Federal or State criminal offenses.

Yes
No

I certify that within the ten (10) year period immediately preceding the submission of this application, I have been convicted of the following Federal and/or State crimes (include description of crime, date of conviction and the State and County of conviction as well as any further description or explanation which you feel would be important to the Fire District review of your application):

Yes
No

Federal and/or State crimes

I understand, consent and agree that the Fire District may conduct a background search/investigation of my Federal and State criminal history and record, including all facts and circumstances surrounding any arrest, charge and conviction as a condition of my acceptance as a volunteer with the Fire District. I further, hereby authorize any Federal or State agency to release to the Fire District any and all records and information of my past criminal record, if any.

I understand that the purpose of this criminal history/record check, past and current employment history and reference check, personal reference check and driver's license check is to assist the Fire District in evaluation my fitness for appointment as a member of the Fire District. I further understand that any prior criminal act committed by me which demonstrates dishonesty or violent behavior or my failure to possess a current valid driver's license is reason to refuse my application for appointment as a member of the Fire District.

I understand and agree that the Fire District may require that I cooperate with alcohol and/or drug testing as a condition of my acceptance as a volunteer with the Fire District. Such testing may be conducted before acceptance, after any accident of which I may be involved, upon reasonable suspicion of my alcohol or drug abuse by my volunteer leadership, at random as part of a Fire District unannounced screening program or as a condition of my return to duty and follow-up conducted in the event of my return to active duty status after any interruption of my active duty for violation of alcohol and/or drug conduct standards or alcohol and/or drug abuse treatment whether voluntarily undertaken or as a condition of continued participation as a volunteer with the Fire District.

I have read the above and know the answers to be true and correct to the best of my ability. Furthermore, I agree to immediately notify the Fire District of any change in my personal, employment and medical status.

I have received and read a copy of the current Fire District By-Laws and/or regulations or operating rules and I understand and agree to abide by all such By-Laws, rules or regulations.

My membership in the North Park Fire Protection District is a public trust and I will not betray the confidence placed in me, as a member of the department. I will not refuse at any time to cheerfully and fully carry out any tasks assigned to me by my superior officers, promptly and to the best of my ability, and will at all times conduct myself in a manner to reflect credit upon the North Park Fire Protection District and myself as a member of the fire department.

I understand and agree that any personal equipment issued to me by the Fire District remains the property of the Fire District and must be used by me only for the purposes designed and intended and must be maintained and protected by me and returned by me upon my termination, for any reason, from active status as a volunteer firefighter or at any time upon demand of the Fire Chief or other duly appointed officer in charge of equipment, in normal operating condition; normal use and wear and tear excepted.

Consent for above statement *

Yes