{"id":245,"date":"2024-10-14T15:03:58","date_gmt":"2024-10-14T19:03:58","guid":{"rendered":"https:\/\/campbelltownshipfire.org\/?page_id=245"},"modified":"2024-10-14T15:09:36","modified_gmt":"2024-10-14T19:09:36","slug":"newhireform","status":"publish","type":"page","link":"https:\/\/campbelltownshipfire.org\/index.php\/newhireform\/","title":{"rendered":"New Hire Form"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-232\"><form id=\"wpforms-form-232\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"232\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/245\" data-token=\"534122aa16677a5b9a1081839a8c8880\" data-token-time=\"1776372797\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\">\t\t<div id=\"wpforms-232-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-232-field_2\" >you accepted, Department?<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-232-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-232-field_3-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"3\"><h3 id=\"wpforms-232-field_3\">Employee Information<\/h3><\/div><div id=\"wpforms-232-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-232-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-232-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-232-field_0-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][0][middle]\" ><label for=\"wpforms-232-field_0-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-232-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-232-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-232-field_17-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_17\">Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-232-field_17\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][17][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-232-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_1\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-232-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-232-field_15-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_15\">Contact Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-232-field_15\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][15]\" aria-label=\"Contact Number\" required><\/div><div id=\"wpforms-232-field_5-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"5\"><label class=\"wpforms-field-label\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-232-field_5\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][5][address1]\" required><label for=\"wpforms-232-field_5\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-232-field_5-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][5][address2]\" ><label for=\"wpforms-232-field_5-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-232-field_5-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][5][city]\" required><label for=\"wpforms-232-field_5-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-232-field_5-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][5][state]\" required><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\"  selected='selected'>Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-232-field_5-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-232-field_5-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][5][postal]\" required><label for=\"wpforms-232-field_5-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-232-field_16-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_16\">Social Security\/Government ID <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-232-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" step=\"any\" required><\/div><div id=\"wpforms-232-field_27-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_27\">Current Employer<\/label><input type=\"text\" id=\"wpforms-232-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\" ><\/div><div id=\"wpforms-232-field_28-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_28\">List any previous Fire\/EMS training or current certifications<\/label><textarea id=\"wpforms-232-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" ><\/textarea><\/div><div id=\"wpforms-232-field_26-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_26\">Employer Phone #<\/label><input type=\"tel\" id=\"wpforms-232-field_26\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][26]\" aria-label=\"Employer Phone #\" ><\/div><div id=\"wpforms-232-field_24-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_24\">Additional Comments or Questions<\/label><textarea id=\"wpforms-232-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" ><\/textarea><\/div><div id=\"wpforms-232-field_29-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"29\"><label class=\"wpforms-field-label\">Are you willing to take all required training? <\/label><ul id=\"wpforms-232-field_29\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_29_1\" name=\"wpforms[fields][29][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_29_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_29_2\" name=\"wpforms[fields][29][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_29_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_30-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"30\"><label class=\"wpforms-field-label\">Are you willing to attend 2-3 meetings per month and special trainings?<\/label><ul id=\"wpforms-232-field_30\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_30_1\" name=\"wpforms[fields][30][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_30_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_30_2\" name=\"wpforms[fields][30][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_30_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_31-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"31\"><label class=\"wpforms-field-label\">Will you follow orders given to you by an officer or senior personnel? <\/label><ul id=\"wpforms-232-field_31\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_31_1\" name=\"wpforms[fields][31][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_31_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_31_2\" name=\"wpforms[fields][31][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_31_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_32-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"32\"><label class=\"wpforms-field-label\">Will you accept and abide by the standard operation guidelines of Campbell Township  Fire Department? <\/label><ul id=\"wpforms-232-field_32\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_32_1\" name=\"wpforms[fields][32][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_32_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_32_2\" name=\"wpforms[fields][32][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_32_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_33-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"33\"><label class=\"wpforms-field-label\">Will you accept and abide by any discipline given by this department? <\/label><ul id=\"wpforms-232-field_33\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_33_1\" name=\"wpforms[fields][33][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_33_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_33_2\" name=\"wpforms[fields][33][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_33_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_34-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"34\"><label class=\"wpforms-field-label\">If 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) <\/label><ul id=\"wpforms-232-field_34\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_34_1\" name=\"wpforms[fields][34][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_34_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_34_2\" name=\"wpforms[fields][34][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_34_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_35-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"35\"><label class=\"wpforms-field-label\">If married, have you discussed joining the department with your spouse? <\/label><ul id=\"wpforms-232-field_35\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_35_1\" name=\"wpforms[fields][35][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_35_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_35_2\" name=\"wpforms[fields][35][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_35_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_36-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"36\"><label class=\"wpforms-field-label\">Are you in good physical health? <\/label><ul id=\"wpforms-232-field_36\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_36_1\" name=\"wpforms[fields][36][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_36_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_36_2\" name=\"wpforms[fields][36][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_36_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_37-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"37\"><label class=\"wpforms-field-label\">A physical is required and paid for by the department. Do you consent to this?<\/label><ul id=\"wpforms-232-field_37\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_37_1\" name=\"wpforms[fields][37][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_37_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_37_2\" name=\"wpforms[fields][37][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_37_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_38-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"38\"><label class=\"wpforms-field-label\">Do 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) <\/label><ul id=\"wpforms-232-field_38\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_38_1\" name=\"wpforms[fields][38][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_38_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_38_2\" name=\"wpforms[fields][38][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_38_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_39-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_39\">If Yes, please list here. <\/label><textarea id=\"wpforms-232-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" ><\/textarea><\/div><div id=\"wpforms-232-field_40-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"40\"><label class=\"wpforms-field-label\">Have you used or do you use illegal narcotics?<\/label><ul id=\"wpforms-232-field_40\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_40_1\" name=\"wpforms[fields][40][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_40_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_40_2\" name=\"wpforms[fields][40][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_40_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_41-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"41\"><label class=\"wpforms-field-label\">Have you had any traffic tickets in the past 5 years? <\/label><ul id=\"wpforms-232-field_41\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_41_1\" name=\"wpforms[fields][41][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_41_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_41_2\" name=\"wpforms[fields][41][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_41_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_43-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_43\">If Yes, please explain.<\/label><textarea id=\"wpforms-232-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" ><\/textarea><\/div><div id=\"wpforms-232-field_42-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"42\"><label class=\"wpforms-field-label\">Do you have a criminal record? <\/label><ul id=\"wpforms-232-field_42\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_42_1\" name=\"wpforms[fields][42][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_42_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_42_2\" name=\"wpforms[fields][42][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_42_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_44-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_44\">If Yes, please explain.<\/label><textarea id=\"wpforms-232-field_44\" class=\"wpforms-field-medium\" name=\"wpforms[fields][44]\" ><\/textarea><\/div><div id=\"wpforms-232-field_45-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"45\"><h3 id=\"wpforms-232-field_45\">Beneficiary Information <\/h3><\/div><div id=\"wpforms-232-field_46-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"46\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-232-field_46\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][46][first]\" required><label for=\"wpforms-232-field_46\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-232-field_46-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][46][middle]\" ><label for=\"wpforms-232-field_46-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-232-field_46-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][46][last]\" required><label for=\"wpforms-232-field_46-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-232-field_47-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"47\"><label class=\"wpforms-field-label\">Address<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-232-field_47\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][47][address1]\" ><label for=\"wpforms-232-field_47\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-232-field_47-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][47][address2]\" ><label for=\"wpforms-232-field_47-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-232-field_47-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][47][city]\" ><label for=\"wpforms-232-field_47-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-232-field_47-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][47][state]\" ><option class=\"placeholder\" value=\"\" selected disabled>--- Select state ---<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-232-field_47-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-232-field_47-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][47][postal]\" ><label for=\"wpforms-232-field_47-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-232-field_48-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_48\">Social Security\/Government ID <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-232-field_48\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][48]\" step=\"any\" required><\/div><div id=\"wpforms-232-field_49-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_49\">Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-232-field_49\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][49][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-232-field_50-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"50\"><label class=\"wpforms-field-label\">I, the submitee, give the Campbell Township Fire Chief my permission to review my driving and criminal record with the local law enforcement. <\/label><ul id=\"wpforms-232-field_50\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_50_1\" name=\"wpforms[fields][50][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_50_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-232-field_50_2\" name=\"wpforms[fields][50][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-232-field_50_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-232-field_52-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_52\">Drivers License #<\/label><input type=\"text\" id=\"wpforms-232-field_52\" class=\"wpforms-field-medium\" name=\"wpforms[fields][52]\" ><\/div><div id=\"wpforms-232-field_53-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-232-field_53\">Interested in:<\/label><select id=\"wpforms-232-field_53\" class=\"wpforms-field-medium\" name=\"wpforms[fields][53]\"><option value=\"Fire\"  class=\"choice-1 depth-1\"  >Fire<\/option><option value=\"EMS\"  class=\"choice-2 depth-1\"  >EMS<\/option><option value=\"Fire 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