Application for Membership - Intern

APPLY TO BECOME A MEMBER

Benton County Fire District #4
What position(s) are you applying for:*

Intern FirefighterLogistics SupportVolunteer FirefighterEMS ProviderOther
GENERAL INFORMATION
Name*

First NameMiddle NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

EDUCATION INFORMATION
Do you have a High School Diploma, GED or Equivalent?*

YesNo
If yes, please attach a copy of the document as proof.

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Have you attended College?*

YesNo
Number of Years Attended
Degrees
You may be required to provide copies of diplomas or transcripts.
If yes, please attach a copy of the document as proof.

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REFERENCES
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

QUESTIONNAIRE
Are you familiar with the job description and requirements?*

YesNo
Do you currently have a valid Washington State Drivers' License?*

YesNo
Do you currently have a valid Washington State Commercial Drivers' License?*

YesNo
Please state in your own words why you are applying for this position:*

EMPLOYMENT INFORMATION
Current Employer
Phone Number
Please enter a valid phone number.
Supervisor's Email
example@example.com
Years with Current Employer
Occupation
Previous Employer
Phone Number
Please enter a valid phone number.
Supervisor's Email
example@example.com
Years with this Employer
Occupation

FIREFIGHTER TRAINING/EXPERIENCE
Agency that provided training/experience
Phone Number
Please enter a valid phone number.
Start Date: End Date:
Description of Training/Experience Received
Agency that provided training/experience
Phone Number
Please enter a valid phone number.
Start Date: End Date:

Have you completed the following testing:

	Yes	No	Score Received
Candidate Physical Ability Test (CPAT)
National Testing Network (NTN)

Description of Training/Experience Received

EMS TRAINING/EXPERIENCE
Agency that provided training/experience
Phone Number
Please enter a valid phone number.
Start Date: End Date:
Description of Training/Experience Received
Current Qualifications

Basic First AidAdvanced First AidFirst ResponderEMTParamedicRNLPNOther

ATTACHMENTS
Thank you for your interest in serving our community as a member of Benton County Fire District #4. We are proud to welcome individuals who are committed to providing the highest level of public safety services, and we look forward to meeting with you.

To process your application, please attach copies of the following required documents:
- 5-Year Driver’s Abstract from the Washington State Department of Motor Vehicles. This can be obtained by visiting thier website: Department of Motor Vehicles
- Washington State Driver’s License
- Current Vehicle Insurance
- Any applicable certifications, licenses, or additional documentation (e.g., EMT, First Aid, CPR)
5-Year Driver's Abstract*

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Washington State Driver's License

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Proof of Vehicle Insurance

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Additional Documentation

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CERTIFICATION
I hereby certify that the answers given in this application are true and correct to the best of my knowledge.
Signature

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