Lacy Lakeview Fire Department Member Application

Lacy Lakeview Fire Department Member Application
The position(s) you are applying for: (check)
Personal Information
Name

First NameMiddle NameLast Name
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Primary Contact Phone
Format: (000) 000-0000.
Alternate/Work Contact Phone
Format: (000) 000-0000.
E-Mail
example@example.com
Are you legally authorized to work in the U.S.?
Do you have any physical or health limitations that could interfere with your performance in the job you are volunteering for?
(Note: Assignment is contingent on meeting minimum physical/mental demands of the position
If you answered yes, please explain
If you answered yes, please explain
4.Do you have any commitments or responsibilities that might prevent you from meeting job requirements?
If you answered yes, please explain
5.Do you have any relatives currently volunteering and/or employed by the Fire Department?
If yes, who?
Have you previously applied for this position?
If yes, when?
Lacy Lakeview Fire Department Member Application
Education and Training
1.High School
Did you graduate?
2.College/Trade School
Subject Major
Did you graduate?
Degree
Please list any skills which you feel relate to this position
4.Have you received Firefighter/E.M.S. training in the past?
Type of Firefighter/E.M.S. training
Date

MonthDayYear
Date
Date
Have you received first aid training in the past?
Type of first aid training
Date last certified

MonthDayYear
Date
Driving Record Check
1.Do you agree to a driver's license record check?
Driver’s license number
State
SSN
YES
Type of vehicle
Driver’s license class (A, B, C)
Endorsements
Lacy Lakeview Fire Department Member Application
Availability and Employment History
1.What hours are you available to respond to emergency calls?
1.Approximate minutes from home to the Fire Station?
2.Approximate minutes from work to the Fire Station?
2.Can you be available for the following meetings and training sessions?
1. Tuesdays / Thursdays, 6:00 p.m

Are you current in your fire certification?

4.Are you current in your EMT certification?
If so, date

MonthDayYear
Date
5.Can you attend an NFPA 1403 Basic (Essential) Training Program?
If so, date

MonthDayYear
Date
6.Can you attend a First Responder or EMT course?
6.Can you attend a First Responder or EMT course?
Supervisor's Name
Phone
Format: (000) 000-0000.
Phone
Format: (000) 000-0000.
Job Title
Date Employed

MonthDayYear
Date
Total Years Employed
Working hours
Working hours
Specific Duties
Does business take you out of town?
If so, please explain normally what hours/days you are out of town
If so, please explain normally what hours/days you are out of town
May we contact your employer?
Please list your Military Service if applicable:
Branch of Service
Reserve Status
Attendance requirements if in the Reserve or Guard
Any mechanical, electrical, or other specialized work experience?
If so, please explain
10.References: Please list three references that are not related to you.
1.Name
Relation
Address
Phone
Format: (000) 000-0000.
2.Name
Relation
Address
Phone
Format: (000) 000-0000.
3.Name
Relation
Address
Phone
Format: (000) 000-0000.
Lacy Lakeview Fire Department Member Application
Should be Empty:

Lacy Lakeview Fire Department Member Application

Personal Information

Lacy Lakeview Fire Department Member Application

Education and Training

Driving Record Check

Lacy Lakeview Fire Department Member Application

Availability and Employment History

Lacy Lakeview Fire Department Member Application