I authorize Upper Merion Township Fire & EMS, King of Prussia Volunteer Fire Company, Swedeland Volunteer Fire Company, and Swedesburg Volunteer Fire Company (collectively, “the Departments”) to conduct a background investigation, including criminal history and child abuse clearances, through the Upper Merion Township Police Department, Pennsylvania State Police, FBI, and/or any other recognized law enforcement or government agency.
I consent to the release and review of my driver’s license information and acknowledge that annual motor vehicle record checks may be conducted.
I understand that a medical examination and drug screening may be required, at the applicant’s expense, to confirm my physical and psychological ability to perform assigned duties and to verify cancer-free status.
I understand that all information obtained will be held in strict confidence and that successful completion of all required background checks is a prerequisite for consideration.
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| Membership Application |
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| Station you're applying for:
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| Membership Type:
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| Date:
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| Name:
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| Address:
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| City:
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| State:
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| Zip Code:
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| Phone Number:
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| Can we text you?:
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| Email Address:
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| Last 4 of Social Security:
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| Date of Birth:
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| Current Age:
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| Emergency Contact Information |
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| Name/Relationship of the person to contact in care of an emergency:
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| Emergency Contact Phone Number:
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| Education |
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| High School Name:
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| High School Address:
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| High School: Number of Years Completed:
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| High School: Year Graduated:
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| College Name :
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| College Address:
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| College: Number of Years Completed:
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| College: Year Graduated :
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| College: Degree Awarded:
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| Background Investigation |
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| Do you have a criminal record (Convictions Only):
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| If YES, please explain :
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| Previous Firefighting / EMS Experience |
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| Agency(s) and Dates associated with those agencies :
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| Certifications: FIRE:
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| Certifications: EMS:
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| Certifications: Incident Management System :
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| Any other certifications / training not previously listed :
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Add Physical Copies of Certifications Here (PDF's only):
Name file:
Last name first initial Cert name.
Example: Smith J FireFighter1
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| References (Please exclude relatives) |
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| Reference 1: Name:
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| Reference 1: Relationship:
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| Reference 1: Address:
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| Reference 1: Organization:
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| Reference 1: Phone Number:
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| Reference 1: Email Address:
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| Reference 2: Name:
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| Reference 2: Relationship:
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| Reference 2: Address:
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| Reference 2: Organization :
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| Reference 2: Phone Number:
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| Reference 2: Email Address:
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| Reference 3: Name:
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| Reference 3: Relationship:
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| Reference 3: Address:
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| Reference 3: Organization :
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| Reference 3: Phone Number:
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| Reference 3: Email Address:
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| Health Information |
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| Is there any reason that your current health could OR would restrict your activities?:
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| If you answered YES, please explain:
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| Would you object to receiving a physical examination?:
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| Record of Convictions |
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| Within the past ten (10) years, have you been convicted of a felony?:
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| If you have, please explain:
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| Have you ever been convicted of, pled guilty to, or pled no contest to any offense involving a minor?:
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| If you answered yes, please explain in detail:
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| All sections of this application must be completed in full and submitted truthfully. Any omission, misrepresentation, or falsification may result in denial of membership or removal from service. |
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Electronic Signature:
By typing your name here, you certify that the information provided in this application is true, complete, and accurate to the best of your knowledge and that you understand and agree to all statements contained herein.
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| Signature Date:
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| Individual Signing:
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| Insurance Coverage Confirmation |
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| Orientation & Command Staff Approval |
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| Final Authorization |
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Thank you for your interest in volunteering with Upper Merion Township Fire & EMS. We appreciate your time, commitment, and desire to serve.
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