Application for Membership

Application for Membership

Become a member of Benton County Fire District #1
What position(s) are you applying for:*

Volunteer FirefighterResident FirefighterSupport ServicesDriver OnlyEMS OnlyFull-Time EmploymentOther
GENERAL INFORMATION
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.

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

YesNo
Have you attended College?*

YesNo
Number of Years Attended
Degrees
You may be required to provide copies of diplomas or transcripts.
Please attach a copy of your High School Diploma or GED/Equivalent:*

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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.
Email
example@example.com
Years with Current Employer
Occupation
Previous Employer
Phone Number
Please enter a valid phone number.
Email
example@example.com
Years with Current Employer
Occupation
Previous Employer
Phone Number
Please enter a valid phone number.
Email
example@example.com
Years with Current 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:
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

EMERGENCY CONTACT INFORMATION
Primary Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize Benton County Fire District #1 to conduct a background investigation for the purpose of verifying the information contained in my application and my fitness for the position that I have applied for or which I may be engaged. I further acknowledge and agree that the District may:
1. Contact my present or former employers.
2. Confirm the status of my drivers' license and driving record.
3. Inquire into any criminal convictions on my record.
4. Contact any personal references provided.
5. Verify my educational background and training.
I specifically authorize any person, firm, or corporation contacted by Benton County Fire District #1 to release any of the above records to the District and waive any priveledge of confidentiality I may have with respects to said records.
Do you have any medical or physical impairment which may restrict you in the performance of your duties as a firefighter?*

YesNo
Is there any reason you would not be available for the work schedule of the position you are applying?*

YesNo
If applying for a position within the Fire District, certain criminal convictions may make you ineligible for membership. If you have been convicted of any of the following, please check and provide information.
Use or sale of narcotics?*

YesNo
Crimes against children under 16 years of age or developmentally disabled persons?*

YesNo
If the answer to any of the above questions is "yes", please explain:
Social Security Number*
Birth Date*

MonthDayYear
Date
Signature*

Clear
Today's Date*

MonthDayYear
Date

ATTACHMENTS
Thank you for your interest in serving our community as a volunteer with Benton County Fire District #1. We are always looking for individuals to deliver the highest level of public safety services to our community, and we look forward to meeting with you. In order to process your application, please attach a copy 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
- Copy of Washington State Drivers' License
- Copy of Current Vehicle Insurance
- Copy(s) of any applicable certifications or licenses (i.e., EMT, 1st Aid, CPR)
5-Year Drivers' Abstract:*

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Washington State Drivers' License:*

Cancelof
Current Vehicle/Auto Insurance:*

Cancelof
Certificates or Licenses:*

Cancelof

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

Clear
Should be Empty:

Application for Membership

GENERAL INFORMATION

EDUCATION INFORMATION

REFERENCES

QUESTIONNAIRE

EMPLOYMENT INFORMATION

FIREFIGHTER TRAINING/EXPERIENCE

EMS TRAINING/EXPERIENCE

EMERGENCY CONTACT INFORMATION

AUTHORIZATION FOR RELEASE OF INFORMATION

ATTACHMENTS

CERTIFICATION