Membership Application

1. Must be a legal resident of the United States of America
2. Must be fluent in the English language
3. Must be a minimum of 18 years of age
4. Must have a high school diploma or equivalent
5. Must have a current valid Illinois drivers license

Nunda Rural Fire Protection District
1713 Route 176
Crystal Lake IL 60014

Employment Application for Paid on Call (POC) and/or Paid on Premise (POP) Firefighter/EMT

Requirements:

All members of the Nunda Rural Fire Protection District are required to maintain their Fire/EMS competencies through both internal and external training programs.

POC applicants must attend department training conducted on Tuesday evening from 7:00pm to 10:00pm. During the first year each new member will be on probation. During this probationary period, you are required to attend and successfully complete the six month rookie training program.

Firefighter II and/or EMT-B must be taken and completed during your first year. Requests due to special circumstances will be reviewed by the Officers for an extension of the time period. Probationary status will continue until such requirements have been completed. State certification in both the Firefighter II and EMT-B must be obtained by the end of the second year.

Qualifications:

Instructions: Fill out completely and accurately. All statements in your application are subject to verification. Fraudulent statements will remove you from consideration. If the space provided is inadequate, reference the section and us the additional comments section at the bottom of the form. Use the term "DNA" (does not apply) if the question does not apply.

If you are emailing this application do not include your social security number. Only include your social security number if you are printing this document to mail to the fire department. THIS IS NOT A SECURE FORM.

To contact us via email, please fill in the information requested below and click on submit

Your Name: Date:

Address: City: State: Zip Code:

Date of Birth:

Do you: Rent Own Other: Years at current address:

Social Security Number: NOTE: If you are emailing this application do not include your social security number.

Email:

Phone Number (with Area Code):

Any previous experience on a fire department or rescue squad? Yes No

If yes, where when

Which class/path would you be interested in? EMT: Firefighter II: Both:

Medical Information:

Date of last physical:

Do you have any physical or physiological conditions that would impair your ability to perform the duties of a Firefighter/EMT?

Yes, please indicate:
No

Vehicle Identification: Make Model Year

Special Training:

Have you completed any special training or educational programs that would applicable for a Firefighter/EMT?

Yes, please indicate:
No

Employment History:

Current Employer
Address
Years employed
Supervisor
Telephone Number
Hours normally worked
Work performed

NOTE: If employed by your current employer for more than ten (10) years, you do not need to complete the prior employer sections below.

Prior Employer
Address
Years employed
Supervisor
Telephone Number
Hours normally worked
Work performed

Prior Employer
Address
Years employed
Supervisor
Telephone Number
Hours normally worked
Work performed

References:

Please provide three (3) references, not related to you, that you have known for at least two (2) years.

Name: Address: Telephone Number:
Name: Address: Telephone Number:
Name: Address: Telephone Number:

Additional Comments:

I hereby authorize the Nunda Fire Protection District to perform a criminal and motor vehicle background check as a requirement of this application.

I have read and understand the above requirements and accept them as conditions for possible employment.

Signature: