Application Form

Central Alexander Fire Department

Membership Application
PO Box 878 Taylorsville, NC 28681

Phone: 828-632-2060
APPLICATION INSTRUCTIONS PLEASE READ AND FOLLOW CAREFULLY
- Must be a US Citizen.
- Must reside in Alexander County.
- Must be at least 18 years old.
- Must have a high school diploma or GED.
- Must not have been convicted of any felonies or serious misdermeanors.
- A seperate application must be completed each time you apply.
- Resumes and cover letters may be submitted with a completed application.
- Incomplete applications will not be considered. Applications that are recieved unsigned, undated, or Incomplete will be eliminated from consideration.
- All applications become property of Central Alexander Fire Department and will not be returned.
- Central Alexander Fire Department is an equal opportunity employer.
It is the policy of Central Alexander Fire Department to prohibit discrimination on the basis of race, gender, greed, national origin, religion, age, or disability in employment or the provision of services.
Personal Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
North Carolina Driver's License Number
Emergency Contact / Information
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
List any medical conditions, allergies, or medications
Education / Other Skills
Did you graduate high school or obtain a GED?

YesNo
If yes, where and date?
Did you graduate from a Vocational / Technical School?

YesNo
If yes, please list the school, date graduated, and degree obtained.
Did you graduate from a College / University?

YesNo
If yes, please list the college, date graduated, and degree obtained.
List below any prior fire or emergency services training or certifications
List any fields of work for which your currently licensed, registered, or certified (give date and sources of issuance)
List any foreign languages in which you are fluent
Present Employment
Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of employment

MonthDayYear
Date
Supervisor's Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Job Title
Shift /days of week normally worked?
Description of work
May We Contact Employer ?

YesNo
Other Information
Have you been a member of this department in the past ?

YesNo
Have you ever been a member of any emergency services ?

YesNo
If yes, please list all
List any past criminal convictions (other than minor traffic violations) and any current pending charges. (If there is none, please enter none)
How did you become interested in becoming a member of this organization?
Why would you like to be a member of this organization?
CERTIFICATION
I certify that all the statements made in this application package and any attached documents are true, complete and correct to the best of my knowledge and belief and are made in good faith. I understand that any false statements or information may be grounds for rejection of my application, or dismissal if I am accepted. I also understand that as a condition of my membership, I may be required to furnish documentation verifying my identity and eligibility to work in the United States. A background check of my driving, criminal, credit or other records may be conducted before acceptance. I permit the Fire Department to conduct a police and court record investigation of my background if relevant to my membership.

I authorize any and all of my current and previous employers, including the US Government or US Military, and other persons, registration and licensing boards, and educational institutions listed on my application, to provide Central Alexander Fire Department with any job- related information requested. I waive the right to legal claims against a disclosing person, employer, or institution and the prospective employer seeking and using information for hiring purposes. Notwithstanding any provisions of Federal or State law, I also waive the right I may have to review confidential material or information received by Central Alexander Fire Department from a person, employer, or institution.

I understand that Central Alexander Fire Department is a drug free workplace and that I may be required to pass a physical examination provided by Central Alexander Fire Department, before I may become a member.

Unsigned applications will not be processed.
Print Full Name
Date Submitted

MonthDayYear
Date
Should be Empty:

Central Alexander Fire Department

PO Box 878 Taylorsville, NC 28681

APPLICATION INSTRUCTIONS PLEASE READ AND FOLLOW CAREFULLY

Personal Information

Emergency Contact / Information

Education / Other Skills

Present Employment

Other Information

CERTIFICATION