Alamosa Fire Department Volunteer Membership Application

ALAMOSA FIRE DEPARTMENT APPLICATION FOR MEMBERSHIP

The Alamosa Volunteer Fire Department is an Equal Opportunity Organization and will consider all applications without regard to race, marital status, sex, age, color, religion, national origin, veteran status, disability or any other characteristic protected by law. It is our intention that all qualified applicants are given equal opportunity and that selection decisions are based on membership and volunteer position factors. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon volunteer position information.
Full Name *

First Name Middle Name Last Name
Current Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Email Address *
Phone Number

Area Code Phone Number
Do you live within Alamosa city limits?

Yes No
Have you previously applied for membership with Alamosa Fire Department? If Yes, give month & year.

Yes No
Month & Year
Are you 19 years of age or older?

Yes No
How did you hear about membership opportunities?

Education

	Name of School	Course of Study	No. of Years Completed	Degree or Diploma
High School or GED
Business/Trade
College

Employment

Please give accurate, complete full-time and part-time employment history including military service. Start with your present or most recent employer FIRST. If self-employed, give firm name and business references. If necessary, attach additional sheets using the same format. NOTE: Membership may be contingent on acceptable references from current and former employers.
Company Name
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Dates Employed
Name of Supervisor *

First Name Last Name
Reason for Leaving
Job title & duties
Company Name
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Dates Employed
Name of Supervisor *

First Name Last Name
Reason for Leaving
Job title & duties
Company Name
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Dates Employed
Name of Supervisor *

First Name Last Name
Reason for Leaving
Job title & duties

Please Check Any that Apply

	Check Box	Expiration Date
Firefighter One Level of State Qualification
Firefighter Two Level of State Qualification
Colorado EMS First Responder
Emergency Medical Technician - Basic
Hazmat Operations level of State Certification
Hazmat Technician level of State Certification
CPR

List proficiency with any heavy machinery, industrial equipment, or specialized training you may have.
List any computer skill you may possess ,i.e., hardware, software applications, programming skills, etc.
Have you been fired from a job or asked to resign in the last 10 years?

Yes No
If Yes, please explain
Do you have a valid driver's license?

Yes No
License Number
License State
License Class
Give three references, not relatives, who have definite knowledge of your business or professional qualifications for the position of volunteer firefighter. Do not repeat names of supervisors listed under employment history.
Name

First Name Last Name
Phone Number

Area Code Phone Number
Name

First Name Last Name
Phone Number

Area Code Phone Number
Name

First Name Last Name
Phone Number

Area Code Phone Number
AFFIDAVIT
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this membership application is true and complete. I understand that any false information or omission may disqualify me from further consideration for membership and may result in my dismissal if discovered at a later date.

I understand that the Alamosa Fire Department may request an investigative consumer report from a consumer-reporting agency. This report may include information as to my character, reputation, personal characteristics, and mode of living obtained from interviews with neighbors, friends, former employers, schools, and others. I understand I have the right to make a written request within a reasonable time for disclosure of the nature and scope of the investigation.

I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employers (except as previously noted), past employers, and organizations named in this application to provide relevant information and opinions that may be useful in making a membership decision. I release such persons and organizations from any legal liability in making such statements.

I understand that if I am extended an offer of membership will be conditioned upon my successfully passing a complete pre-engagement physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capacity to do the work for which I am applying.

I understand that if I am extended an offer of membership, I will be required to successfully pass a drug screening examination. I hereby consent to a pre-engagement drug screen as a condition of membership.

I UNDERSTAND THAT THIS APPLICATION FOR MEMBERSHIP DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR DOES ANY OFFER OF MEMBERSHIP GUARANTEE MEMBERSHIP FOR ANY DEFINITE PERIOD OF TIME.

I have read, understand, and by my signature consent to these statements:
Upload Resume
Signature *

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

ALAMOSA FIRE DEPARTMENT APPLICATION FOR MEMBERSHIP

Employment

Give three references, not relatives, who have definite knowledge of your business or professional qualifications for the position of volunteer firefighter. Do not repeat names of supervisors listed under employment history.