Firefighter Application Form

Firefighter Application Form
Desired Position*
Personal Information
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Driver's License State*
Driver's License Number*
Driver's License Expiration Date*

MonthDayYear
Date
Driver's License Restrictions
Cell Phone Number*
Home/Work Phone*
Email*
example@example.com
Residence Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you legally entitled to work in the United States?*
Are you 18 years of age or older?*
Do you possess a valid Driver’s License and a good driving record?*
Employment Information
Education
High School Diploma or Equivalent*

YesNo
Date Graduated*

MonthDayYear
Date
Highest Level of Education*
Name and Location of Institution/College*
Skills and Experience
Please indicate if you have any of the following skills or training*

Firefighter CertificationRescue Technician CertificationEMTHazardous MaterialsCurrently Enrolled in a Fire AcademyNoneOther
Previous Emergency Services Experience - Explain:
List Organization Name/Location, Position, Dates Employed, Reason For Leaving, and Contact Person Information
Area of Interest*

Firefighter OnlyEMS OnlyFire and EMSAdministrative and SupportPublic EducationSwift Water RescueOpen Water Dive
Criminal Background
Have you ever been charged with a felony?*
If yes, complete the following:
Have you ever been charged with or convicted of driving offenses other than minor traffic violations?*
If yes, complete the following:
Have you ever been charged with or convicted of 3, or more, minor moving traffic violations of the same or similar nature, and/or charged with or convicted of 3, or more, misdemeanors in the last 3 years?*
If yes, complete the following:
References

(Non Family, Known at Least 5 Years)
Include at least 2 references.
Date

MonthDayYear
Date
Signature
Should be Empty:

Firefighter Application Form

Personal Information

Employment Information

Education

Skills and Experience

Criminal Background

References