The positions you are applying for: (required)

Junior Firefighter

Firefighter/First Responder

Support Staff

Last Name (required)

First Name (required)

Middle Name (required)

Street Address (required)

City (required)

State (required)

Zip (required)

Phone Number (required)

Driver License # (required)

Issuing State (required)

Photo of Driver License (FRONT) (required)

Photo of Driver License (BACK) (required)

Do you live within the Fire District or within 5 miles of the Fire District: (required)

Yes

No

Are you willing to attend training sessions: (required)

Yes

No

Are you willing to respond to emergency calls, day or night: (required)

Yes

No

Why do you want to be a volunteer of the Millersville Rural Fire Protection District: (required)

Have you ever been convicted of a felony: (required)

Yes

No

What is your highest level of education completed: (required)

Do you have any volunteering experience: (required)

Yes

No

If yes, please explain experience:

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Employer Information:

Present Employer:

Supervisor's Name:

Employer Address:

Employer Phone Number:

Year Employed:

Job Title:

Working Hours:

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Military Service, if applicable

Branch of Service:

Years of Service:

Type of work performed:

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Fire Certifications: Please upload all certifications in 1 file

Basic Fire

Yes

No

Firefighter 1

Yes

No

Firefighter 2

Yes

No

NIMS

Yes

No

Medical Training

First Responder

EMR

EMT

EMT-A

EMT-P

No Medical Training

Hazmat Training

Awarness

Operations

Technician

No Hazmat Training

Certification Upload:

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References: Include Name, Phone, and Personal or Professional Reference

Reference 1: (required)

Reference 2: (required)

Reference 3: (required)

Signature:

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Review Electronic Records and Signatures Policy (required)

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Review Electronic Records and Signatures Policy (required)

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