Alamosa Fire Department Volunteer Membership Application

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

Do you live within Alamosa city limits?

YesNo

Have you previously applied for membership with Alamosa Fire Department? If Yes, give month & year.

YesNo

Month & Year

Are you 19 years of age or older?

YesNo

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

Company Name

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Dates Employed

Name of Supervisor*

First NameLast Name

Reason for Leaving

Job title & duties

Company Name

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Dates Employed

Name of Supervisor*

First NameLast Name

Reason for Leaving

Job title & duties

Company Name

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Dates Employed

Name of Supervisor*

First NameLast 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?

YesNo

If Yes, please explain

Do you have a valid driver's license?

YesNo

License Number

License State

License Class

Name

First NameLast Name

Phone Number

Area CodePhone Number

Name

First NameLast Name

Phone Number

Area CodePhone Number

Name

First NameLast Name

Phone Number

Area CodePhone 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:

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Signature*

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.