Application for Membership - Intern

APPLY TO BECOME A MEMBER

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

Other
GENERAL INFORMATION
Name

First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

EDUCATION INFORMATION
Do you have a High School Diploma, GED or Equivalent?
If yes, please attach a copy of the document as proof.

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Have you attended College?
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
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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?
Do you currently possess a valid driver's license that allows you to legally operate a motor vehicle in Washington State?
Do you currently possess a valid Commercial Driver's License (CDL) or are you eligible to obtain one if required for the position?
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.Format: (000) 000-0000.
Supervisor's Email
example@example.com
Years with Current Employer
Occupation
Previous Employer
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Start Date: End Date:
Description of Training/Experience Received
Agency that provided training/experience
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Start Date: End Date:

Have you completed the following testing:

Rows	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.Format: (000) 000-0000.
Start Date: End Date:
Description of Training/Experience Received
Current Qualifications

Other

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
Benton County Fire District #4 is an Equal Opportunity Employer. The District does not discriminate in recruitment, selection, appointment, training, promotion, retention, or other terms and conditions of employment or volunteer service based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other status protected by applicable federal, state, or local law.

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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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