Jay Volunteer Firefighter Application Form
Station #1 Lower: 157 Revoir Flat Rd / Station #2 Upper: 4550 VT Route 242 Mailing Address: 1036 VT Route 242 Jay, VT 05859
Personal Information
Name
*
First Name
Last Name
Residence Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
*
-
Area Code
Phone Number
Alternate Phone
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Marital Status
*
Single
Married
# of Dependents
*
Height (feet)
*
feet
Height (inches)
*
inches
Wieght
*
lbs
Basic Information
Employer Name
Name of Person/Business
Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Phone
*
-
Area Code
Phone Number
Do you possess a valid Driver’s License?
*
Do you have a current Commercial Driver’s License (CDL)?
*
Do you believe you are free of medical conditions that may preclude your participation as a volunteer firefighter?
*
Physical Disabilities/ Limitations
Additional Comments
Skills and Experience
Please indicate if you have any of the following skills or training
*
CPR - Cardiopulmonary resuscitation
Certified Trade - mechanic, electrician
Fire Safety Systems - alarms, extinguishers
Rescue procedure - lifeguard, auto extrication
First Aid
Knowledge of breathing apparatus - scuba diving, etc
PAD/Defibrillation Training
Occupational Health & Safety
Other
Previous Emergency Volunteer Experience - Explain:
Previous Firefighter Experience – Explain:
List Firefighter Schools, if any, including Military School:
Terms and Conditions
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: