VOLUNTEERS WANTED

Last Name (required)

First Name (required)

Middle Name (required)

Present Address (required)

City (required)

Zip (required)

How long have you lived there? (required)

Own or Rent (required)

Date of Birth (required)

Age (required)

Home Phone (required)

Social Security Number (required)

Work/Pager Phone (required)

Mobile Phone (required)

E-mail Address (required)

In emergency notify: (required)

Relationship (required)

Phone Number for Emergency Contact (required)

Do you have a drivers license? (required)

Yes

D/L# (required)

Expires (required)

State (required)

Class (required)

Have you had your license suspended or revoked? (required)

Yes

If yes, give details

Any Endorsements? (required)

Yes

If yes, give details

Have you ever been a member of any U.S. Fire Department? (required)

Yes

If yes:

Department name and location

Position Held

Start Date

End Date

Department name and location

Start Date

End Date

Department name and location

Start Date

End Date

Have you ever been a member of the military? (required)

Yes

If yes:

Branch of Service

Start Date:

End Date:

Type of Discharge

Rank at Discharge

Present military obligations

Education

High School Name

High School Address

High School Years

Diploma Earned?

Yes

College or University Name

College or University Address

Years Attended

Degree or Certificate Earned

Major/Minor/Etc.

Technical School Attended Name

Technical School Attended Address

Years Attended

Degree or Certificate Earned

Fire or EMS Training or Experience

Fire School Name

Fire School Address

Fire School Years Attended

Job Experience

Degree/Diploma

Major/Minor ETC.

EMS School Attended

EMS School Address

EMS School Years Attended

Degree/Diploma

Major/Minor ETC.

Other

Name of Training/Experience

Address of Training

Years

Degree or Certificates Earned

Health

Do you have any physical condition(s) which might limit you in performing the duties expected of a firefighter? (required)

Yes

If yes, explain

Employment

You will be expected to answer fire calls when available. What are your normal working yours, including travel time? If you work shifts, please indicate your rotation schedule. (required)

Current Employer (required)

Address (required)

Job Title (required)

Start (required)

End (if not current/leaving)

Reason for Leaving (if applicable)

Summarize your job duties

References: List references other than relatives who are familiar with your qualifications

Name (required)

Address (required)

Phone (required)

Relationship

Name (required)

Address (required)

Phone (required)

Relationship

Name (required)

Address (required)

Phone (required)

Relationship (required)

History

Have you ever been convicted of a felony, gross misdemeanor or misdemeanor? (required)

Yes

If yes, briefly describe the circumstances of your conviction indicating date, nature and place of the offense and disposition of the case. Your answer is looked upon as only one of the factors considered in the decision and is evaluated in terms of nature, severity, and date of offense.

Please explain why you believe you would be an asset to our organization (required)

Additional Comments?

I certify that all statements made on this application are true, complete and correct to the best of my knowledge and belief. I understand that my statements are subject to verification. I also understand that falsification on this application will disqualify me from acceptance or could result in my subsequent dismissal. I understand that it is my responsibility to submit any changes in my availability or phone and address in writing. (required)

Yes

If accepted for probationary membership you will have to pass a physical prior to starting any fire department duties. The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion or national origin.

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VOLUNTEERS WANTED

Minimum Requirements

Benefits

Apply Using the Form Below!

Minimum Requirements

Benefits

Apply Using the Form Below!

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