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First name

Middle Initial

Last name

Email

Phone

Position

Country/Region

Address

City

Zip / Postal code

Can you prove you are 18+ years old?

Yes

No

If hired, can you provide the necessary documents to verify you're authorized to work in the U.S.?

Yes

No

Have you ever been convicted of a felony?

Yes

No

If required for the position, will you submit to Fingerprinting?

Yes

No

If required for the position, will you submit to Background Check?

Yes

No

If required for the position, will you submit to Drug Test?

Yes

No

If "yes' above, please explain

Years of firefighting experience

Useful Skills / Certificates

Other skills and/or certifications not noted above

Do you have any commitments that might prevent you from attending monthly meetings, training, emergency call outs, or special events?

Yes

No

If "yes' above, please explain

Have you applied to this Department before?

Yes

No

Do you have any previous firefighting experience?

Yes

No

Do you have any prior emergency medical experience?

Yes

No

Have you ever been fired or discharged from an employer?

Yes

No

If 'yes' above, please explain

Type of vehicle owned:

Year / Make / Model

Vehicle License #

Drivers license Number & Exp. Date

Are you able to leave your job for emergency calls?

Yes

No

Are you able to regularly attend meetings and trainings held every Wednesday night?

Yes

No

Emergency Contact

First Name

Last Name

Phone

References

First Name

Last Name

Phone

First Name

Last Name

Phone

First Name

Last Name

Phone

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AUTHORIZATION

"I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that, if my membership is accepted, falsified statements on the application shall be grounds for dismissal form the Denair Volunteer Fire Department.

I authorize investigation of all statements contained herein and the references listed above to give you and all information concerning any pertinent information they may have, personal, or otherwise and release the Denair Volunteer Fire Department and the Denair Volunteer Firefighters Association from any liability for any damage that may result from the utilization of such information.

I also understand and agree that no representative of the Denair Volunteer Fire Department has any authority to enter into any agreement for membership for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by the Fire Chief of the Denair Volunteer Fire Department."

Signature