Firefighter Application Form
Desired Position
*
Please Select
Volunteer
Part-Time
Full-Time
Personal Information
Name
*
First Name
Middle Name
Last Name
Cell Phone Number
*
Format: (000) 000-0000.
Home/Work Phone
*
Format: (000) 000-0000.
Email
*
example@example.com
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
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
*
Yes
No
Date Graduated
*
-
Month
-
Day
Year
Date
Highest Level of Education
*
Please Select
09
10
11
12
Some College
Trade School
Four Year College/University
Graduate Degree
Name and Location of Institution/College
*
Skills and Experience
Please indicate if you have any of the following skills or training
*
Firefighter Certification
Rescue Technician Certification
EMT
Hazardous Materials
Currently Enrolled in a Fire Academy
None
Other
Previous Emergency Services Experience - Explain:
List Organization Name/Location, Position, Dates Employed, Reason For Leaving, and Contact Person Information
Area of Interest
*
Firefighter Only
EMS Only
Fire and EMS
Administrative and Support
Public Education
Swift Water Rescue
Open 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
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: