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Background Information

EMPLOYER INFORMATION:
Name of Current Employer: *
Address*
City*
Province*
Postal Code*
Phone Number*
Is your employer aware of you making this application to The Lesser Slave Regional Fire Services?*
1. Yes
1. No
Employers/Supervisors Name: *
Employers Supervisors Phone Number:*
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COMMITMENT INFORMATION:
Which Fire Hall are you applying for? *
The fire department participates in a number of educational and safety programs to enhance awareness about fire safety. This may require additional hours of volunteering from our firefighters, would you support and participate in these programs?
1. Yes
1. No
ARE YOU ABLE TO RESPOND TO EMERGENCY INCIDENTS DURING:
Check all that apply *
1. Daytime
1. Nights
1. Weekends
Do you work shift work?
1. Yes
1. No
Are you able to respond to emergency calls during hours of work?
1. Yes
1. No
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EXPERIENCE AND TRAINING:
Please list any firefighting experience that you may have received:
Experience #1*
Please include timeline, Department Name, Position, and Contact Name of previous position
Experience #2
Please include timeline, Department Name, Position, and Contact Name of previous position
Experience #3
Please include timeline, Department Name, Position, and Contact Name of previous position
Please list other training you may have obtained, eg: First Aid, CPR, H2S, Confined Space, WHIMIS, TDG, etc.*
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EMPLOYMENT HISTORY:
Employment #1*
Please include position held, contact name, and contact number of your current/past employment
Employment #2
Please include position held, contact name, and contact number of your current/past employment
Employment #3
Please include position held, contact name, and contact number of your current/past employment
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I, the applicant, acknowledge that being a member of the fire department is a commitment of time and energy and I agree to attend and participate in training programs as provided. I understand that occupational health and safety regulations state that being clean shaven is a requirement for the use of self contained breathing apparatus. I also understand that any costs incurred for providing the above required/or requested information is my responsibility. I, the applicant do hereby swear that all information is true and accurate and consent to reference and security checks should it be required.
Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature*
The Lesser Slave Regional Fire Service is collecting the personal information on this form for the purpose of possible membership to the Fire Service, under the authority of the Freedom of Information and Protection of Privacy Act, Section 32 (c). For more information you may contact the Lesser Slave Regional Fire Service at 901 4th Street NW, Slave Lake, or call the Fire Chief at 780.849.4110.

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