Medical Information Do you have any physical disabilities, mental disabilities or chronic diseases that affect your ability to perform the essential functions of firefighting duties? Yes No If yes, explain: Statement of Veracity Review your answers carefully and read the statement below before signing I represent and warrant that the answers I have given are complete and true to the best of my knowledge and belief. I further acknowledge that I have read and understand the questions regarding criminal records and my background, and that I have answered these questions thoroughly and truthfully. I understand that failure to answer all questions completely and sincerely will subject me to dismissal from the Liberty Fire Department. ___________________________________ _________________________ Applicant’s Signature Date signed
Medical Information Do you have any physical disabilities, mental disabilities or chronic diseases that affect your ability to perform the essential functions of firefighting duties? Yes No If yes, explain: Statement of Veracity Review your answers carefully and read the statement below before signing I represent and warrant that the answers I have given are complete and true to the best of my knowledge and belief. I further acknowledge that I have read and understand the questions regarding criminal records and my background, and that I have answered these questions thoroughly and truthfully. I understand that failure to answer all questions completely and sincerely will subject me to dismissal from the Liberty Fire Department. ___________________________________ _________________________ Applicant’s Signature Date signed
North-Liberty-Fire-Department-Volunteer-Application.docx