City of Canton

References

Please list two references other than relatives.*

Certifications

Please complete below and submit copies, if available, of any fire fighting related courses you have completed.

1) Course (optional)

2) Date (optional)

3) Name

4) Date Completed (optional)

5) Location (optional)

6) Name

7) Position

8) Course (optional)

9) Street Address

10) Date Completed (optional)

11) Location (optional)

12) Address Line 2 (optional)

13) CPR for Healthcare Providers or Red Cross equivalent (optional)

14) Company

15) Phone

16) Date Completed (optional)

17) Please list any other specialty courses in which you are currently certified

18) City

Application Form Waiver

Please read carefully the consideration of membership application by Canton Volunteer Fire Department.

19) ZIP Code

20) First Name of Applicant

Fire Department Experience

22) Last Name of Applicant

23) 1. Name of Department/Association (optional)

24) Date

25) Street Address (optional)

Important

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.

26) How long at current address? (optional)

27) Address Line 2 (optional)

28) Social Security No.

29) Are you under age 18?

Yes

No

30) City (optional)

31) Are you currently certified as an EMT in the State of South Dakota?

Yes

No

32) State (optional)

33) ZIP / Postal Code (optional)

34) When could you start?

35) High School (optional)

Name Of School,Location,Number Of Years Completed,Degree

36) Country (optional)

37) Phone (optional)

38) College (optional)

Name Of School,Location,Number Of Years Completed,Degree

39) Bus. or Trade School (optional)

Name Of School,Location,Number Of Years Completed,Degree

40) Name of Last Chief (optional)

(First and Last)

41) Professional School (optional)

Name Of School,Location,Number Of Years Completed,Degree

42) Date of Service (optional)

From:

43) Date of Service (optional)

To:

44) 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

45) Job Title

46) Please enter name for release of the association to perform a background check at no cost to the applicant: (optional)

47) 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.

48) Date (optional)

49) License Number

Membership Description/Policy

51) 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

52) Classification

Operator

Commercial (CDL)

53) Do you have any pre-existing medical or physical conditions that will interfere with performing emergency response, or fire fighting activities?*

Yes

No

54) After reviewing the above membership description, please indicate if you are able to perform the essential functions of the above described duties.

Yes

No

55) Have you had any moving violations during the past five years?

Yes

No

56) Have you had any accidents during the past five years?

Yes

No

57) Would your work permit you to answer fire alarms, the majority of the time, day or night?

Yes

No

58) Would you be willing to make Fire Department an important organization in your life, not just social function, but realizing that human lives may depend on us, + thousands of dollars worth of property

Yes

No

59) 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?

e.g: meetings, training, fighting fires, etc., away from your family life

Yes

No

60) 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

61) Department asks that every new member spend at least three days each year at State Fire School, usually held June 1st. Would you able, willing, barring unforeseen circumstances, to devote attendance?

Yes

No

62) 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

63) 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 (optional)

Please omit any information that would disclose your race, gender, age, marital status, ethnic origin, religious or political affiliations, or disability.

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