HomeMy WebLinkAbout2023-02-02 Volunteer Firefighter Application Form
County of Newell Fire Services
Application Form
Name: ___________________________________________________________________________
Mailing Address: ___________________________________________________________________
Phone Numbers: ________________________ (Home) ______________________________ (Cell)
IOS or Android: _______________________ E-mail Address: _________________________________
Birthday: ____________________________________________ (must be at least 18 years of age)
Emergency Contact (Name/Phone Number): _____________________________________________
Social Insurance Number: ___________________ Alberta Health Number: ____________________
*Must provide to receive yearly honorarium*
Do you have any medical conditions that would prevent you from firefighting duties? _____________
________________________________________________________________________________
Alberta Operator’s License Class & Endorsements: _____________________________________
A clear colour photocopy of the driver’s license {front & back} must be submitted with this application.
Probationary or Graduated Driver’s licenses will not be accepted.
Place of current employment: ____________________________________________________
How long have you been employed at your current job? __________________________
Do you object to us contacting your employer for references? Yes No
Do you object to a doctor’s examination for physical fitness? Yes No
Have you had any previous Fire Fighting experience? If so, where? _______________________
_____________________________________________________________________________
Why do you wish to join the Fire Department? ________________________________________
_____________________________________________________________________________
% of time you are in town and available for calls? Day _____% Night _____%
Are you a Canadian Citizen? _____ Landed Immigrant? _______
Have a Work Visa with at least a two (2) years’ work period remaining? _____
References (at least three (3), include names + telephone numbers) (preferably work related):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I do hereby declare that should I be successful in my application for membership as a volunteer
member of the Fire Department, I will obey and abide by the rules and regulations, standing orders,
job duties, etc. of the Fire Department and if I fail to comply with these rules, I understand that I will
be subject to disciplinary action. I understand that if accepted that I will be on six months’ probation
and that at any time during this probationary period, I may be asked to leave the Department for
conduct unacceptable by the Fire Chief. I certify that all statements in this application are true. I
agree and understand any misstatement of material facts in this application will cause loss of all right
to volunteer with any County of Newell Fire Department.
{All pending applications will remain on file for a period of six (6) months. After that time
applications and supporting documents will be destroyed and applicants are invited to apply
again.}
Date: _____________________________________________________________________
Signature of Applicant: _______________________________________________________
*Please provide a criminal record check/vulnerable sector check with the application form.
See letter attached. This letter must be taken to the RCMP Station to have the check
completed. Once you have received your criminal record check/vulnerable sector check back,
please provide the original to your Fire Chief.
Fire Chief or Deputy Chief Use Only (please fill this out)
Received by: _____________________________________________________________________________________
(Print name and sign)
Approved by: _____________________________________________________________________________________
(Print name and sign)
Date of approval: __________________________________________________________________________________
PHYSICAL, MENTAL AND EDUCATIONAL REQUIREMENTS
This page must accompany the application form
Firefighting can be physically and mentally demanding. The work environment requires the ability to
react quickly and remain calm under stressful situations. Applicants must possess agility and stamina
to perform all functions of this position under adverse conditions.
Therefore, all applicants shall be aware, that if the application is accepted by the Fire Department,
that the following (and/or other) job requirements may present themselves and that the applicant can
be expected to perform these or similar duties.
1) Wear Turnout Gear including Self Contained Breathing Apparatus (SCBA) weighing around 23
kg while performing firefighting and rescue duties.
2) Climb stairs in full turnout gear and SCBA while carrying additional weight of around 12 kg.
3) Drag 60m of 65mm fire hose and nozzle a distance of 60m.
4) Carry tools and equipment over uneven ground safely.
5) Work on ladders at heights in excess of 20m.
6) Crawl distances of around 15 m.
7) Work on roofs at various heights.
8) Drag weights around 70 kg for distances of around 8m.
9) Work in enclosed spaces.
10) Perform duties indoors and outdoors in all types of weather, day or night.
11) Complete the NFPA 1001 Level 1 and Level 2, and NFPA 472 within the first three (3) years
on the department. These courses are provided by the County of Newell (free of charge) but
require a time commitment of 3-5 weekends/year and an exam.
12) Attend bi-weekly practices approximately two (2) hours in length.
The applicant acknowledges the above (and/or other) job related skills that he/she may be asked to
perform while on the job, in a classroom and/or in practice sessions.
By signing below the undersigned acknowledges that to the best of his/her knowledge he\she can
perform these duties/tasks safely without hurting themselves, co-workers or the general public.
Date: _________________________________________________________
Name of Applicant: _____________________________________________
please print clearly
Signature of Applicant: __________________________________________
COUNTY OF NEWELL FIRE SERVICES
This page must accompany the application form
To: All County of Newell Fire Fighting Members
Re: Failing to Drive in a Responsible Manner
Referenced Documents: Alberta Traffic Safety Act and Regulations
SOG #005 - Responding in Non-Emergency Vehicles
Important Context: All members shall obey all the rules of the road when responding to the Fire Hall
or Incident Scene using Non-Emergency Vehicles. For the Departments using
Green Flashing Lights, these lights do not give any member permission to
contravene the Traffic Safety Act.
If a substantiated offence occurs the Department will enforce the following:
First Offence A “Verbal Warning” will be issued to the member by the Fire Chief or his/her
designate. A note of the verbal warning will be put in the Drivers File for that
member.
Second Offence A “Written Warning” will be issued to the member by the Fire Chief or his/her
designate and the documentation will be put in the Drivers File for that member
as a matter of record.
Third Offence A “Written Warning” and a “One Month Suspension” from the Department
will be issued to the member by the Fire Chief or his/her designate and the
documentation will be put in the Drivers File for that member as a matter of
record.
Fourth Offence The member “Will be Removed from the Department” on a permanent basis.
First offence Verbal Warning note and Second and Third offence Written Warnings will be removed from the
Drivers File after a period of two (2) years from the date of the written warning providing no other problems
have
arisen.
I have read and understand the above Internal Policy and agree to abide by it:
Dated at _____________________ Alberta the _______ Day of ___________________, 20____
Members Name: __________________________________________________________________________
Members Signature: _______________________________________________________________________
This document shall be kept in the members Drivers File at the County of Newell.
To Whom it May Concern,
The County of Newell, Fire & Emergency Services requests the following volunteer fire applicant to complete a
Criminal Record/Vulnerable Sector search.
I ________________________________________, have applied to become a volunteer firefighter with the
County of Newell.
Fire Department: ________________________________________________________
Driver’s License #: _______________________________________________________
(2 pieces of ID are required in person at the Police Station, with this letter)
Signature: ______________________________________________________________
Date: __________________________________________________________________
Thank you,
__________________________________________
Stewart Luchies
Newell Regional Fire Chief
DIRECT DEPOSIT AGREEMENT FORM
Authorization Agreement
I ( ) hereby authorize the County of Newell to initiate automatic deposits
to my account at the financial institution named below.
This agreement will remain in effect until the County of Newell receives a written notice of cancellation from me
or my financial institution, or until I submit a new direct deposit form to the Payroll Department.
Account Information
Name of Financial Institution:
Address:
Institution #:
Branch:
Account Number: ☐ Checking | ☐ Savings
Signature
Authorized Signature (Primary): Date:
Authorized Signature (Joint): Date:
PLEASE ATTACH A VOIDED CHEQUE OR DEPOSIT SLIP AND RETURN THIS FORM TO PAYROLL.
183037 RR145 (Box 130), Brooks, AB T1R 1B2 Check us out on social
media
Phone: 403-362-3266
Fax: 888-361-7921
Email: administration@newellmail.ca
Web: www.countyofnewell.ab.ca
Driver Abstract Consent and Disclosure
Whereas,
______________________________________ (the “Employee”),
(Name of Employee)
who is employed in the position of _____________________________________ agree to the following:
(Position)
Driver’s License #:_____________________________ Date of Birth:____________________
(Day/Month/Year)
1. I authorize the County of Newell to obtain a Drivers’ abstract for my employment records on
an annual basis.
2. I declare that I have had no reportable vehicle accidents in the last calendar year.
3. I agree to notify the County of Newell immediately of any changes in class, conditions or
validity my driver’s license.
This agreement will be in effective for the duration of my employment with the County of Newell.
Signature: __________________________ Date: __________________