MOWBRAY VOLUNTEER FIRE DEPARTMENT
PROGRAM INFORMATION
DIRECTIONS
1. Read entire packet.
3. If you are still interested, complete the documents included within this packet.
4. Along with completing the above documents, please submit the following documents:
a. Proof of Automobile Insurance
b. Copy of Drivers License
MOWBRAY VOLUNTEER FIRE/RESCUE
1705 Mowbray Pike
SODDY DAISY, TN 37379
423 332-9658
APPLICATION FOR VOLUNTEER
I. PERSONAL HISTORY
DATE ______
Name: ______
Last First Middle
Address: ______
Street City State Zip
Telephone: ______
Social Security No. ______
Cell phone: ______
Pager No. ______
Date of Birth: ______
Drivers License No.______
E-Mail Address: ______
Height ______Weight ______Hair Color ______Eye color______
How long have you lived at the above address? ______
Previous Addresses (Give complete addresses for past 5 years): ______
______
______
______
US citizen: or do you have a visa permitting you to work in the U.S.: Yes ___No__
Personal References:
Name: ______Address: ______Phone: ______
Name: ______Address: ______Phone: ______
Name: ______Address: ______Phone:______
Have you ever been arrested? ______
If yes, state dates, charges, locations an dispositions:______
______
______
VehicleInsuranceCompany:______
Do you possess a valid Tennessee State Drivers License? Yes______No______
If no, is there any reason you might be barred from obtaining one?
______
______
Describe any physical defects or disabilities, including vision that may affect you at the scene of emergencies:______
II. CURRENT EMPLOYMENT
BusinessName/Address:______
______
Type of Business: ______
Job Title: ______Supervisor’s Name/Title______
Employed (Mo. /Yr.): From: ______To: ______
Describe duties in detail: ______
______
Previous employment from the past five years:
______
______
______
III. RECORD OF EDUCATION
Minimum requirements for the position of Firefighter are to be a high school graduate or have a G.E.D. Do you have a high school diploma or G.E.D.? Yes ____ No_____
If no you will be required to obtain your G.E.D. within two (2) years of submitting your application!
IV. FIRE SERVICE EXPERIENCE
Department: ______Dates of Service: ______
Department: ______Dates of Service: ______
Other: ______
V. MILITARY SERVICE
Were you ever in the U.S. Military Service? Yes ______No ______
Dates of service: From______To: ______
Was your discharge or separation under honorable conditions? Yes______No______
Branch of service: ______
THE FACTS SET FORTH IN MY APPLICATION FOR EXAMINATION ARE TRUE AND
COMPLETE. I UNDERSTAND THAT IF QUALIFIED FOR EXAMINATION, OR EMPLOYED, FALSE STATEMENTS ON THIS APPLICATION SHALL BE CONSIDERED SUFFICIENT CAUSEFOR DISMISSAL. YOU ARE HEREBY AUTHORIZED TO MAKE ANY INVESTIGATION OF MYPERSONAL HISTORY THROUGH ANY INVESTIGATIVE AGENCIES OF YOUR CHOICE.
SIGNATURE ______DATE ______
VOLUNTEER REQUIREMENTS
1. Entrance requirements
a. Minimum Age Limit. The minimum age limit for a volunteer firefighter shall be
sixteen (16) years of age. The minimum age limit to drive a department
apparatus shall be twenty-one (21) years of age.
b. Criminal Background Checks. As required by S.O.P. will be made, as
well as random checks during your tenure with the department.
c. Physical Agility and Physicals. Every applicant for membership shall be required to:
Pass the Fire Department physical fitness evaluation.
d. Firefighters responding from home will comply with S.O.P.s
e. Firefighters living outside of the M.V.F.D limits are considered “Out of
Area” and will follow the guidelines of the MVFD SOP .
2. Application and Initial Training Process
a. Applications for volunteer firefighters are accepted any time.
b. Applicants will be scheduled for an interview/oral board.
c. All applicants will be invited to a department orientation. We strongly encourage your spouse or significant other to attend the orientation. The orientation will discuss:
Operation of the Fire Department
The recruit training program
d. Firefighter candidates shall complete an approved firefighter academy. This
course is approximately 9 months to complete. It will be required that the recruit
firefighter be available for evening and weekend training during this time period.
A passing grade is mandatory.
Exception. Applicants who have previously completed an approved
firefighter academy may have this requirement waived on approval
of the Training Division. Proof will be required and/or an evaluation
check will be performed by the Training Division.
e. After completion of the Firefighter Academy, the probationary period will
commence. This probation period will take the Trainee Firefighter from the basic
Level recruits to that of Probationer Firefighter. The Probationary Firefighter should have all objectives met within 1 year.
f. After completing all performance objectives established, the Training Officer
shall make a review of the Probationary Firefighter and a recommendation shall be made with regards to the status of the Probationary Firefighter.
g. Each Probationary Firefighter shall be issued an alpha pager and assigned to
a. Company Officer. In area people will also be issued a minitor 5. The Company Officer is the first point of contact in the chain of command if any situations or problems arise. The Company Officer shall conduct written evaluations of each
assigned Probationary Firefighter.
VOLUNTEER FIREFIGHTER PHYSICAL ASSESSMENT
(Conducted by the Exercise Science Center)
It is the intent of the Mowbray volunteer Fire Department to allow men and women who are interested in being Volunteer Firefighters a reasonable opportunity to do so, but also be reasonably sure they can physically perform the job.
Certain tasks, such as lifting and raising ladders, carrying, moving, and dragging hose bundles and charged hose lines, working in high places such as roofs and tops of ladders while wearing and additional 50 or more pounds of protective clothing and equipment requires certain physical abilities that are necessary for the job.
As an applicant for the position of volunteer firefighter, it is crucial that you be fully aware of the aspects of this job. This self-evaluation form is designed to help you determine whether or not you would be willing to devote your time to serve this department and your community.
Please read the instructions carefully before completing each part of the evaluation.
This is not a test. A negative response to a question does not mean an automatic rejection of
your application. Your answers should reflect how you feel.
Part I
The following is a list of tasks and working conditions typical of the job of volunteer firefighter.
Read them carefully and then check ( ) the appropriate box:
Yes:
This means that you are willing to perform this duty or work in this environment.
No:
This means that you are not willing to perform this duty or work in this environment.
1. Risk your personal safety to save another life or someone else’s property.
Yes ( ) No ( )
2. Work around persons who are sick, injured, dying or dead.
Yes ( ) No ( )
3. Console persons who have lost everything and/or those who have lost family members or friends. Yes ( ) No ( )
4. Work closely with fellow volunteers and professional firefighters. You may have to deal with personality conflicts. Yes ( ) No ( )
5. Be interrupted from your meals, holidays and other family activities.
Yes ( ) No ( )
6. Be interrupted from your sleep. Yes ( ) No ( )
7. Be asked to assist in cleaning apparatus and equipment, after an emergency, regardless of time of day. Yes ( ) No ( )
8. Be expected to perform at a high level of competency regardless of your physical or emotional state. Yes ( ) No ( )
9. Be under the critical eye of the public and may have to deal with unruly or abusive individuals. Yes ( ) No ( )
10. Work under the stress of highly emotional and dangerous situations such as falling debris or walls, extreme heat, poisonous or explosive gases, smoke, falling electrical wires, and other hazardous situations. Yes ( ) No ( )
11. May be exposed to persons who have contagious illnesses or diseases.
Yes ( ) No ( )
12. Be expected to obey strict rules, regulations, and orders.
Yes ( ) No ( )
13. Respond to situations where you will be asked to pump out basements and other chores
not related to fighting fires or treating the ill or injured.
Yes ( ) No ( )
14. At the fire scene, spend 5% of your time fighting fires and 95% cleaning
up afterwards.
Yes ( ) No ( )
15. Work hard in all kinds of weather and you will become very dirty and
sweaty. Yes ( ) No ( )
16. Have to deal with a public who does not always understand or appreciate
what you do. Yes ( ) No ( )
17. Be expected to complete a Firefighter Recruit Training Academy and attend all classes and study sessions. Yes ( ) No ( )
18. Be expected to drill every Monday night between 18:00 and 22:00 plus an occasional Saturday drill after finishing the Academy. Yes ( ) No ( )
Part II
The following is a list of personal qualities or characteristics, which are essential to doing a good job as a volunteer firefighter. Read each item carefully and then check ( ) the appropriate box.
Yes: This means that you feel you have this quality.
No: This means that you feel that you do not have this quality.
This is not a test. A negative response to a question does not mean and automatic rejection of your application. Your answers should reflect how you feel.
1. Do you perform well under adverse conditions of cold, heat, or stormy weather? Yes ( ) No ( )
2. Are you mentally alert when awakened suddenly from sleep? Yes ( ) No ( )
3. Can you work in enclosed or high places? Yes ( ) No ( )
4. Do you have respect for authority and discipline? Yes ( ) No ( )
5. Do you have courage? Yes ( ) No ( )
6. Are you dependable? Yes ( ) No ( )
7. Do you have concern for people, including people you don’t know?
Yes ( ) No ( )
8. Do you have common sense? Yes ( ) No ( )
9. Do you have good integrity and are you honest? Yes ( ) No ( )
10. Can you work as a team member? Yes ( ) No ( )
11. Are you “cool-headed” in a tough or emergency situation? Yes ( ) No ( )
PART III – DRIVING RECORD
1. Have you had any accidents in the past five years involving DUI, reckless driving, hit and run, or driving while your license was suspended or revoked?
Yes ( ) No ( )
2. Regarding your driving record (use the following point schedule), have you
accumulated more than six (6) points in the past two (2) years, or more than ten (10) points in the past five (5) years? Yes ( ) No ( )
3. Has your driver’s license ever been suspended or revoked as a habitual traffic
offender? Yes ( ) No ( )
PART IV – DRUGS
1. Have you used marijuana or its derivative within one year prior to making application for the position of volunteer firefighter? Yes ( ) No ( )
2. Have you used any other controlled substances (not prescribed for you by an authorized individual) within the last three years? Yes ( ) No ( )
3. Have you used marijuana or its derivative more than 25 times? Yes ( ) No ( )
4. Have you used any opiate (i.e. heroin, morphine, opium, etc) not prescribed for you by a Physician? Do not include the occasional use of cough syrup or minor pain medicine, which contains codeine, such as aspirin with codeine. Yes ( ) No ( )
5. Have you ever used any hallucinogenic drugs (excluding marijuana or its derivative) such as LSD, PCP, mushrooms, etc.? Yes ( ) No ( )
6. Have you used cocaine more than three (3) times? Yes ( ) No ( )
7. Have you used other controlled substances (not prescribed for you by an authorized individual) more than ten (10) times? This includes the total usage of all other controlled substances such as speed, amphetamines, barbiturates, and tranquilizers. Yes ( ) No ( )
8. Have you ever been arrested for any controlled substance? Yes ( ) No ( )
Use this space for any comments or explanations to the questions above
______
______
______
This information is confidential and will only be viewed by administration in determining the eligibility of the applicants.
Name: ______
Please print
Date: ______
Signature: ______
CONFIDENTIAL DISCLOSURE REPORT Mowbray Volunteer Fire Department, at the time it accepts an application
for the position of volunteer firefighter, obtain the following information from the
applicant, when hires, may have unsupervised access to children under sixteen (16) years of age
or developmentally disabled persons or vulnerable adults during the course of employment or where a volunteer may have access to groups of five(5) or fewer children under twelve (12) and sixteen (16) years of age, or developmentally disabled persons or vulnerable adults. To comply with the statutory requirements, please provide the following information under oath:
1. Have you been convicted of any crime against children or other persons?
Yes ( ) No ( )
2. Have you been convicted of crimes relating to financial exploitation of a vulnerable
adult? (See definition – next page) Yes ( ) No ( )
3. Have you been found in any dependency action under RCW 13.34.040 to have sexually assaulted or explicated any minor or to have physically abused any minor?
Yes ( ) No ( )
4. Have you been found by a court in domestic relations proceedings to have sexually abused or exploited any minor or to have physically abused any minor?
Yes ( ) No ( )
5. Have you been found in any disciplinary board final decision to have sexually or
physically abused or exploited any minor or developmentally disabled person or to have
abused or financially exploited any vulnerable adult? Yes ( ) No ( )
6. Have you been found by a court in a protection proceeding under chapter 73.34 RCW, to have abused or financially exploited a vulnerable adult? Yes ( ) No ( )
Dated: ______
Applicant Acknowledgement
A crime against children or other persons is defined by the statute as: