New Hire Form Please enable JavaScript in your browser to complete this form.Employee InformationName *FirstMiddleLastDate of Birth *Email *Contact Number *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSocial Security/Government ID *Current EmployerList any previous Fire/EMS training or current certificationsEmployer Phone #Additional Comments or QuestionsAre you willing to take all required training? YesNoAre you willing to attend 2-3 meetings per month and special trainings?YesNoWill you follow orders given to you by an officer or senior personnel? YesNoWill you accept and abide by the standard operation guidelines of Campbell Township Fire Department? YesNoWill you accept and abide by any discipline given by this department? YesNoIf you are accepted, will you commit to serve three years or more on the Campbell Township Fire Department? (You will be required to reimburse the department for your training if you leave the department before 3 years without just cause) YesNoIf married, have you discussed joining the department with your spouse? YesNoAre you in good physical health? YesNoA physical is required and paid for by the department. Do you consent to this?YesNoDo you have any physical or medical problems that could affect your health while working with the fire department/rescue? (Ex: Diabetes, Asthma, Heart Problems, etc) YesNoIf Yes, please list here. Have you used or do you use illegal narcotics?YesNoHave you had any traffic tickets in the past 5 years? YesNoIf Yes, please explain.Do you have a criminal record? YesNoIf Yes, please explain.Beneficiary Information Name *FirstMiddleLastAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code meetings standard accept Social Security/Government ID *Date of Birth *I, the submitee, give the Campbell Township Fire Chief my permission to review my driving and criminal record with the local law enforcement. YesNoDrivers License #Interested in:FireEMSFire & EMSSubmit