Online Volunteer Application Volunteer Form General Info (All Information Must be Completed)Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth MM slash DD slash YYYY Social Security Number PhoneEmail Personal Status Single Married Divorced Other If Married, Spouse's Name Children Medical InfoHeight Weight Eye Color Hair Color Blood Type Allergies Driver's InfoState Driver's License Number Class Expiration Date MM slash DD slash YYYY Employment InfoOccupation Employer Supervisor's Name Phone Number Number of Years Employed May We Contact to Verify Employment YES NO Education InfoGrade School Years Attended High School Years Attended Graduate YES NO College/Business/Trade Special Skills Criminal HistoryDo you have any current arrests and/or convictions for misdemeanors or felonies? YES NO If yes, explain Has driver's license ever been suspended or revoked? YES NO If yes, explain Military ServiceBranch Last Rank Entry Date Discharge Date Type of Discharge Present Status Special Training Previous Fire Fighter ExperienceHave you ever been a member of another Fire Department? YES NO If yes, please provide the followingFire CompanyStart Date to End DateCertification Earned Add RemoveFire Schools/Training/Certifications Line Officer Position/Commendations/Awards References - Please provide 3 other than relativesName First Last Relationship PhoneName First Last Relationship PhoneName First Last Relationship PhoneConsent(Required) I agree to this consent form"I hereby certify that the information contained in this application form, is true and correct to the best of my knowledge. I fully understand that any falsifications on said application would be grounds for the disqualification of the applicant. I hereby authorize the Bethel Park Volunteer Fire Company to have a criminal history, driving record, child abuse history and personal reference checks performed by an independent investigator, an investigation by the Bethel Park Police Department and/or any authorized member of the Bethel Park Volunteer Fire Company. The criminal history and child abuse check may include a local and national police check. I understand that if my application is accepted by the Bethel Park Volunteer Fire Company that I will be on Fire Company probation for a period of at least twenty four (24) months. After twelve months (12) of my probationary period the Fire Department Membership may may terminate my membership for any reason deemed valid according to our by-laws. All qualified applicants will be considered without regard to race, color, religion, national origins, ancestry, sex, disabilities or age (40 and over). All information requested on this application form is solicited for the purpose of determining abilities and skills required for membership into the Bethel Park Volunteer Fire Company and to facilitate verification for the information requested. I hereby acknowledge that I have read this section of the membership application and fully understand the meaning and effect of signing this form.