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Key West Volunteer Fire/EMS Department
Volunteer Application
Personal Information
Are you aware this application is for Key West Fire Department in Dubuque, Iowa?
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Name
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First Name
Middle Name
Last Name
DOB
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
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Area Code
Phone Number
Email
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example@example.com
Residence Address
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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
Approximate living distance from the station
Emergency Contact
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Relation
Name (First & Last)
Phone
Social Security Number
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Basic Requirements
Are you 18 years of age or older?
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Do you have a valid drivers license?
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Availability
If accepted by the Fire Department, you will be required to attend regular weekly Monday night training at 6:00PM. Can you meet this requirement?
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Are you willing and able to wear an emergency pager and respond to emergencies?
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Are you willing and able to participate in the occasional weekend training program?
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Have you ever served on other fire or EMS departments?
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If yes:
Skills and Experience
Please indicate if you have any of the following skills or training
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Emergency Medical Technician/ Paramedic
CPR - Cardiopulmonary resuscitation
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 EMS or Firefighting Experience - Explain:
Any special training or skills:
Hobbies:
Reason for Application:
Additional Comments:
References
Reference (3-4)
Primary Employer
Name of Business
Street Address
City/State/Zip
Phone Number
Would you be able to respond for emergencies during work hours?
Secondary Employer
Name of Business
Street Address
City/State/Zip
Phone Number
Would you be able to respond for emergencies during work hours?
May we contact the employers listed above?
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Memberships in other organizations:
Terms and Conditions
Certification of Application
I hereby certify that the information provided in this Application for Membership is true,correct and complete and contains no misrepresentations or falsifications. I am aware that, ifaccepted, any misstatement or omission of fact on this application may result in my dismissal.Also, I realize the Key West Fire/EMS Department is not a social club; and that as a member I will be required to give freely of my time to attend emergency calls, fires, meetings, drills,departmental functions and serve on committees. I further authorize the Key West Fire/EMS Department to conduct criminal backgroundchecks and to investigate the validity of the information provided
Signature
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorization and Release
Having made application for membership and desiring the Key West Fire/EMS Department tobe informed of my record(s), I hereby authorize the Key West Fire/EMS Department toinvestigate my record(s) and I further authorize the addressed individual(s), company(ies) orinstitution(s) to furnish the Key West Volunteer Firefighters with any information which mayconcern my records and do hereby release the addressed individual(s), company(ies) orinstitutions(s) and all persons whomsoever from any damage on account of furnishing suchinformation
Signature
Submit
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