EOMFD Volunteer Application

Thank you for your interest in membership with the East Orchard Mesa Fire Department. Please read the information provided below regarding the membership requirements.

The East Orchard Mesa Fire Department is an all volunteer department and does not compensate it's members for time spent for department commitment. This includes, but is not limited to, training, department meetings, community outreach, department activities, or call attendance. Compensation is limited to State or Federal wildland deployments.

Requirements
- Must have a current driver's license
- Must be a minimum age of 18
- Must currently have or obtain ICS 100, 200, 700, 800 within the first 6 months
- If you do not hold an fire certifications, it is required that you attend a Firefighter Type II course (wildland) and State Firefighter I (structural) course.
- To participate in the medical program, you must hold or obtain a Colorado State EMT or Paramedic license.
- If you do not currently hold a CPR hold, you must attend a CPR course at or outside the department
- Pass a department held emergency driver's course, physical agility testing, and pass a background check.
- Must be able to attend monthly meetings, as well as upkeep 36 hours of fire training annually
- Able to fill shifts (6 am - 6 pm)
- Read, understand, and adhere to the East Orchard Mesa Fire Department Standard Operating Guidelines and Procedures handbook
Job commitment of a volunteer is to be willing and able to respond to Emergency and Non-Emergency Medical, Fire, and Rescue calls day or night in possible adverse weather conditions.

Demographics
Full Name

First NameMiddle NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Social Security Number
xxx-xx-xxxx
Driver's License Number
Driver's License State of Issue
Driver's License Expiration Date

MonthDayYear

Employment History
Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Supervisor

First NameLast Name
Phone Number

Area CodePhone Number
Employed From

MonthDayYear
Date
Employed To

MonthDayYear
Date
Responsibilities
May we contact?

YesNo
Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Supervisor

First NameLast Name
Phone Number

Area CodePhone Number
Employed From

MonthDayYear
Date
Employed To

MonthDayYear
Date
Responsibilities
May we contact?

YesNo
Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Supervisor

First NameLast Name
Phone Number

Area CodePhone Number
Employed From

MonthDayYear
Date
Employed To

MonthDayYear
Date
Responsibilities
May we contact?

YesNo

Certifications
Are you Currently Certified in CPR?
What is your EMS Level of Certification

EMR (First Responder)EMTIntermediateParamedic
Are you Colorado State Certified?
CO State EMS #
CO State EMS Expiration Date

MonthDayYear
Are you National Registry Certified?
NREMT #
NREMT Expiration Date

MonthDayYear
Are you a Certified Firefighter?
What is your Level of Fire Certification?

FF1FF2
Firefighter Certification Expiration Date

MonthDayYear
Are you Hazmat Certified?
Hazmat Certification Level

AwarenessOperationsTechnician
Hazmat Certification Expiration Date

MonthDayYear
Are you Wildland Certified?
If so, what are your Qualifications?

Emergency Services Experience
Do you have any Emergency Services Experience?
If so, please answer the questions below
Department Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What was your Position?
Contact Name

First NameLast Name
Phone Number

Area CodePhone Number
Employed From

MonthDayYear
Date
Employed To

MonthDayYear
Date
Duties:
Department Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What was your position?
Contact Name

First NameLast Name
Phone Number

Area CodePhone Number
Employed From

MonthDayYear
Date
Employed To

MonthDayYear
Date
Duties:
Department Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What was your Position?
Name

First NameLast Name
Phone Number

Area CodePhone Number
Employed From

MonthDayYear
Date
Employed To

MonthDayYear
Date
Duties:

Education
Highschool
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From

MonthDayYear
Date
To

MonthDayYear
Date
Graduated?
Degree
College
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From

MonthDayYear
Date
To

MonthDayYear
Date
Graduated?
Degree
College
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From

MonthDayYear
Date
To

MonthDayYear
Date
Graduated?
Degree

Health Questionaire
Do you have any Allergies?
If so, please list them below
Allergies
Do have any medical conditions past or present that may interfere with your job performance?
If so, please list your medical history below
Medical History
Are you able to lift and move 100 lbs or more?

Driving History
Do you have one or more moving violations within the last 3 years?
If yes, please list them here

Professional References

Please List Three Professional References
Name

First NameLast Name
Relationship
Company
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Relationship
Company
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Relationship
Company
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Documents

Upload your Resume, Cover Letter, Driver's License, and any Certifications below
Browse Files

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By signing below I acknowledge that I have read and understand the statements and requirements listed above.

I certify that my answers are true and complete to the best of my knowledge and ability and authorize the East Orchard Mesa Fire Department to verify any and all of the information that I have provided herein.

I understand review of this application alone does not constitute offer to volunteer.

If this application leads to an offer, I understand that false and misleading information in my application or interview may result in termination from the East Orchard Mesa Fire Department.
Typing in your name constitues as a digital signature for this application.
Digital Signature

First NameLast Name
Date

MonthDayYear
Date
Time

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