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Home
Our Community
History & Community Profile
Cornerstones
Schools
Parks
Churches
Airport
Organizations
Library
Shopping
Healthcare
Utility Suppliers
Real Estate
Summer Recreation
Swimming Pool
Visit Canton
Places to Eat
Places to Shop
Recreation
Newton Hills State Park
Hiawatha Golf Course
Chautauqua Park
City Parks
The Canton Depot
Doing Business
Chamber Of Commerce
Economic Development
Canton Industrial Park
Permits
Planning & Zoning
Your Government
Report Street Light Outages
Snow Information
Departments
Ordinances
Commissions & Boards
Agendas
Permits
Planning & Zoning
Upcoming Events
Employment Opportunities
Volunteer Membership Application
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Volunteer Membership Application
Canton Volunteer Fire Department Membership Application
Date
Personal Information
Name
*
First
Middle
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
How long at current address?
Phone
*
Social Security No.
Are you under age 18?
*
Yes
No
Are you currently certified as an EMT in the State of South Dakota?
*
Yes
No
If "No", are you nationally Registered by the NREMT?
*
Yes
No
When could you start?
Educational Background
High School
Name of School
Location
Number of Years Completed
Degree
College
Name of School
Location
Number of Years Completed
Degree
Bus. or Trade School
Name of School
Location
Number of Years Completed
Degree
Professional School
Name of School
Location
Number of Years Completed
Degree
Have you ever been convicted of a crime which is substantially related to the functions or qualifications of the position for which you are applying?
*
(a Conviction record will not necessarily disqualify you from membership)
Yes
No
If Yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed and type(s) of rehabilitation.
Please enter name for release of the association to perform a background check at no cost to the applicant:
First
Last
Date
Drivers License
Canton Volunteer Fire Department requires a valid drivers license to operate the trucks. Please complete the following section.
License Number
State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Classification
*
Operator
Commercial (CDL)
Have you had any accidents during the past five years?
*
Yes
No
If Yes, how many?
Have you had any moving violations during the past five years?
*
Yes
No
If Yes, how many?
References
Please list two references other than relatives.
*
Name
Position
Company
Phone
Use below space to elaborate on any background, experience, or qualifications that you believe should be considered in evaluating your qualifications for membership. You may include hobbies, volunteer experience and any other activities you believe relevant.
Please omit any information that would disclose your race, gender, age, marital status, ethnic origin, religious or political affiliations, or disability.
Fire Department Experience
1. Name of Department/Association
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Phone
Name of Last Chief
First
Last
Date of Service
From
To
Job Title
Enter your last job title:
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this fire department.
Membership Description/Policy
Canton Volunteer Fire Department personnel are frequently required to lift heavy objects/persons. On-call status requires residing in the City of Canton or available and within the city limits. Association members are required to attend bi-monthly meetings and education. Confidentiality of service calls is mandatory at all times. Membership is contingent on majority vote of current members. A probationary period of three (3) months is in effect, during which time you may be disqualified as a member without recourse if the Canton Volunteer Fire Department feels your membership is not in the best for the fire department and/or the community of Canton.
Applicants agree to become a South Dakota Certified Firefighter within 2 years of application. This includes successfully taking required training classes, and associated tests.
The City of Canton, and the Canton Rural Association are the proprietors of the fire trucks and the Canton Volunteer Fire Department provides staff. Members are required to become familiar with all aspects of the fire department including operation, equipment location, and general maintenance.
Emergency response requires that are able to lift equipment, patients, etc., repeatedly. Do you have any limitations that would impede you from this requirement?
*
Yes
No
Do you have any pre-existing medical or physical conditions that will interfere with performing emergency response, or fire fighting activities?
*
Yes
No
If so, please provide documentation of course of treatment and name, address, and phone number of treating physician.
MD Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Phone
After reviewing the above membership description, please indicate if you are able to perform the essential functions of the above described duties.
*
Yes
No
If you answered "No", please identify any duties that you cannot perform. If a reasonable accommodation is required to enable you to perform the duties properly and safely, please describe:
Would your work permit you to answer fire alarms, the majority of the time, day or night?
*
Yes
No
Would you be willing to make the Fire Department an important organization in your life, not just a social function, but realizing that human lives may depend on us, plus thousands of dollars worth of property?
*
Yes
No
Would your spouse, or significant other, have objections of making the Fire Department an important organization in your lives together, knowing that a significant amount of time could be spend in meetings, training, fighting fires, etc., away from your family life?
*
Yes
No
Our regular meetings are the first and third Mondays of each month. Would you be willing, and able, to attend these meetings on a regular basis?
*
Yes
No
The Department asks that every new member spend at least three days each year at State Fire School, usually held the first of June. Would you able, and willing, barring unforeseen circumstances, to devote this time to attend?
*
Yes
No
One Sunday each spring and fall, there is a District Fire School. Would you be able to attend these schools, on a regular basis?
*
Yes
No
Certifications
Please complete below and submit copies, if available, of any fire fighting related courses you have completed.
Course
Date Completed
Location
Course
Date Completed
Location
Course
Date Completed
Location
CPR for Healthcare Providers or Red Cross equivalent
Date Completed
Please list any other specialty courses in which you are currently certified:
Course
APPLICATION FORM WAIVER
PLEASE READ CAREFULLY
In exchange for the consideration of my membership application by Canton Volunteer Fire Department:
Neither the acceptance of this application nor the subsequent entry into any type of membership relationship, either in the membership position applied for or any other position, and regardless of the contents of personnel manuals, policy statements and the like as they may exist from time to time, or other Canton Volunteer Fire Department practices, shall serve to create an actual or implied contract of membership, or to confer any right to remain a member of Canton Volunteer Fire Department, or otherwise to change in any respect the membership-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Fire Chief of the Fire Department. Both the undersigned and Canton Volunteer Fire Department may end the membership relationship at any time, without specified notice or reason. If membership is granted, I understand that the Canton Volunteer Fire Department may unilaterally change or revise their policies and procedures.
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Canton Volunteer Fire Department permission to contact schools, all previous associations (unless otherwise indicated), references and others and hereby release the Canton Volunteer Fire Department from any liability as a result of such contract.
I understand that, in connection with the routine processing of your membership application, the Canton Volunteer Fire Department may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics and mode of living. Upon written request from me, the Canton Volunteer Fire Department, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.
I further understand that my membership with the Canton Volunteer Fire Department shall be probationary for a period of ninety (90) days and further that any time during the probationary period or thereafter, my membership relationship with the Canton Volunteer Fire Department is terminable at will for any reason by either party.
*
I agree that I have read and understood each of the above sentences.
Name of Applicant
First
Last
Date
Canton Volunteer Fire Department does adhere to a policy of making membership decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, are or disability. We assure you that your opportunity for membership with Canton Volunteer Fire Department depends solely on your qualifications.