Application

Before you begin: This application requests personal information used during the membership selection and background-review process. Complete it on a private device and do not submit information for another person.

Required: Fields marked with * must be completed before the application can be submitted. Use a Not Applicable box only where one is provided.

01 · APPLICANT INFORMATION

ABOUT YOU

First Name *

Middle Name *

Last Name *

Date of Birth *

Driver's License Number *

Driver's License State *

Street Address *

City *

State *

ZIP Code *

Previous Addresses * NO PREVIOUS ADDRESSES

List addresses from the last 10 years, including city, state, ZIP and approximate dates. If the checkbox is selected, no text is required.

Email *

Confirm Email *

Phone Number *

02 · EMPLOYMENT & EDUCATION

BACKGROUND

Current Employer * NOT CURRENTLY EMPLOYED

Employer name, address and telephone number. If the checkbox is selected, no text is required.

Last Two Previous Employers * NO PREVIOUS EMPLOYERS

List employer name, address and telephone number. If the checkbox is selected, no text is required.

High School Diploma or GED? *Illinois fire and EMS certifications require a high school diploma or GED equivalent.

High School and Graduation Year *

03 · REFERENCES

PERSONAL REFERENCES

References must not be related to you and should have known you for at least two years.

Reference #1

Full Name *

Phone Number *

Street Address *

City *

State *

ZIP Code *

Reference #2

Full Name *

Phone Number *

Street Address *

City *

State *

ZIP Code *

Reference #3

Full Name *

Phone Number *

Street Address *

City *

State *

ZIP Code *

04 · PHYSICAL ABILITIES

CHECK ALL THAT APPLY

I can stand for prolonged periods. I can sit for prolonged periods. I can reach above my shoulders. I can lift 75 pounds. I can work on slippery and/or uneven surfaces. I can work protracted or irregular hours.

05 · ACKNOWLEDGMENTS

CERTIFICATION & SIGNATURE

I understand a drug test may be performed as part of the hiring process or during membership. *

I understand a criminal background check will be performed as part of the hiring process and may be performed periodically. *

I understand that misrepresentation, falsification or deliberate omission of information may result in failure to be offered membership, or dismissal if discovered after appointment. *

Signature — Type Your Full Name Including Middle Name *Typing your name constitutes your electronic signature on this application.

By submitting, you certify that the information provided is true and complete to the best of your knowledge. A timestamp and originating IP address are recorded with the submission for administrative integrity.

ABOUT YOU

BACKGROUND

PERSONAL REFERENCES

Reference #1

Reference #2

Reference #3

CHECK ALL THAT APPLY

CERTIFICATION & SIGNATURE