NAME: ________________________________________________________________

PHONE: ____________________

ADDRESS:
______________________________________________________________________

HOW LONG AT PRESENT ADDRESS? __________________________

PREVIOUS ADDRESS:
______________________________________________________________________

DATE OF BIRTH: ________________      SOCIAL SECURITY NO: _________________

DRIVER'S LICENSE NO: _____________________________      STATE: ________

OCCUPATION: ____________________________________________________

EMPLOYER: ______________________________________________________

EMPLOYER'S ADDRESS:
______________________________________________________________________

EMPLOYER'S PHONE: _____________________________

ARE YOU ABLE TO RESPOND TO CALLS FROM WORK? ___________

PREVIOUS FIRE DEPT. EXPERIENCE: ________________ YEARS

EMS CERTIFICATION? ________      LEVEL: ____________________

                    STATE: _______      ID NO: ______________________

FIREFIGHTER CERTIFICATION? ______      LEVEL: _________________

                    STATE: _______

FIRE TRAINING COURSES COMPLETED (PLEASE LIST AND PROVIDE COPIES OF CERTIFICATES):




HAVE YOU EVER BEEN CONVICTED OF A CRIME? ______    IF SO, PLEASE EXPLAIN:




DO YOU HAVE ANY DISABILITIES OR PHYSICAL LIMITATIONS TO YOUR ACTIVITIES?




ON THE BACK OF THE APPLICATION, WRITE A BRIEF STATEMENT OF WHY YOU WISH TO JOIN THIS DEPARTMENT, WHAT THE DEPARTMENT CAN GAIN FROM YOUR MEMBERSHIP, AND WHAT YOU EXPECT TO GAIN FROM MEMBERSHIP.

YEARLY DUES OF $1.00 MUST BE SUBMITTED WITH THIS APPLICATION. AN INTERVIEW WITH THE FIRE CHIEF PRIOR TO BOARD REVIEW IS REQUIRED.

SIGNED: _______________________________________   DATE: _________________