Apply

Fill out the form below and we'll be in touch.

Personal Information

Last name

First name

Street / Route

City

State

ZIP code

Date of birth

Age

Social Security Number

Driver's License #

DL State

DL Expiration

Phone number

Email address

Previous Service

Have you been a member of a fire department?

Yes

List all training and/or special skills beneficial to the department

Are your training records available?

Yes

References

Please provide three references with telephone numbers.

Reference 1

Name

Phone number

Reference 2

Name

Phone number

Reference 3

Name

Phone number

Background

Have you ever been convicted of a felony?

Yes

Signature

I, _______________, give my permission to the Pottsville Fire Department to perform a criminal background check with local and state law enforcement. I attest that the information I have provided in this application is true, and I understand that should it be determined at a later date that I have falsified any information on this application, it will be grounds for immediate dismissal from the Department.

Type your full name below to sign electronically.

Signature

Date