PersonalFirst Name *Middle NameLast Name *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Email Address *Phone *EducationHigh School *9101112Diploma/ Degree *YesNoSchool/ City, State *College or Vocational School1234Diploma/Degree EarnedSchool/ City, StateFire Certification ( If you are not certified, please leave blank)Fire Certification UploadChoose FileNo file chosenDelete uploaded fileEMS Certification ( If you are not certified, please leave blank)Iowa Certification NumberExpiration DateEMS Certification UploadChoose FileNo file chosenDelete uploaded fileRecord of ConvictionHave you ever been convicted of a crime other then minor traffic offense?YesNoIf Yes, fully explain:EmploymentPlease list employment history, with your current employer first ( including U.S. Military Service), for the last 10 years, If any employment was under a different name, indicate name.Employer:Position:Street AddressCityState/ProvinceZIP / Postal CodePhoneSupervisorDate FromDate toType of EmploymentFull-TimePart-TimeReason for LeavingEmployer:Position:Street AddressCityState/ProvinceZIP / Postal CodePhoneSupervisorDate FromDate toType of EmploymentFull-TimePart-TimeReason for LeavingEmployer:Position:Street AddressCityState/ProvinceZIP / Postal CodePhoneSupervisorDate FromDate toType of EmploymentFull-TimePart-TimeReason for LeavingEmployment ContinuedExplain any gaps in work history:Have you ever been discharged or asked to resign from a job, or resigned to avoid termination?YesNoIf Yes, explain:Have you ever been an applicant or member of any fire or rescue agency?YesNoIf so, please state agency name, location, contact information, and dates of membership:Please Describe any additional work experience, volunteering, community involvement, or training:ReferencesNamePhoneStreet AddressCityState/ProvinceZIP / Postal CodeRelationNamePhoneStreet AddressCityState/ProvinceZIP / Postal CodeRelationNamePhoneStreet AddressCityState/ProvinceZIP / Postal CodeRelationApplicant's Certification and Agreement * I hereby certify that the facts set forth in the above application are true and complete to the best of my knowledge. I authorize the Delaware Township Fire Department, its officers, and or the Delaware Township Trustees to verify their accuracy and to obtain reference information by contacting educational institutions, references or employers, and to rely on the use such information as they see fit. I hereby release the Delaware Township Fire Department, its Officers, and the Delaware Township Trustees from any/all liability of whatever kind and nature that, at any time, could result from obtaining and having a membership decision based on such information. This application and all information obtained is the property of the Delaware Township Fire Department. I understand that, if granted membership, falsified statements of any kind or omission of facts called for on this application, regardless of the time of discovery, shall be considered sufficient basis for dismissal. I understand that should and offer of membership be extended to me and accepted that i will fully adhere to the policies, rules, and regulations of the department. However, I further understand that neither the policies, rules, regulations of membership nor anything said during the interview process shall be deemed to constitute the terms of an implied contract for continued membership. I understand that any membership is for an indefinite duration and at will and that either I or the department may terminate my membership at any time with or without notice or cause. I understand that if I am offered membership, membership is conditioned upon my providing such other and further information as may be required by the Delaware Township Fire Department, its Officers,and or the Delaware Township Trustees. Yes, I agree with the privacy policy and terms and conditions.Signature *Start signing your signature hereYour browser does not support e-Signature field.Delaware Township Fire Department Service Commitment *I hereby commit to: Provide volunteer on call service including days, nights, weekends and holidays and agree to meet the minimum attendance requirements as established by the Delaware Township Fire Department. Attend required monthly business and training meetings. Maintain Fire & EMS certifications and complete all required skills drills. Comply with the standard operating guidelines, policies, and procedures of the department and the direction of the command staff at all times. Maintain patient Confidentiality. I understand membership is at-will, and may be terminated at any time with or without cause by the Delaware Township Fire Department, its Officers, and or the Delaware Township Trustees.Signature *Your browser does not support e-Signature field.Submit Application