First Name
Last Name
Fire Police
Address
City

State
Zip
Email
Home Phone
Business Phone
Fire Fighter
Junior Member
Social Member
I am interrested in:  (check all that apply)
MI
Ages 14 - 18

Thank You for wanting to join our Fire Team.
Please fill in ALL information fields in the form below.

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County
Date of Birth
Are You A US Citizen?
Yes
No
Drivers License Number
Is this a CDL License?
Yes
No
Are you a(n): First Responder?
EMT?
Paramedic?
EMS Cert. Number
Education:
High School Graduate or GED?
If no, highest grade completed
College Graduate?
Yes
No
College Attended
Major course of study
Degree Earned
Yes
No
Work Experience
Present or Last job
Name of Employer:
Address:
Supervisor's Name & Phone Number:
Hours per week
Job Duties:
Reason for leaving
Name of Employer:
Address:
Supervisor's Name & Phone Number:
Hours per week
Job Duties:
Reason for leaving
Next most resent job:
Fire Department Experience:
Name of Fire Department:
Address:
Chief's Name
Telephone Number
Positions Held
Certificates or training you have completed:
Please provide 3 unrelated personal referances  include Name,Address,Phone Number
Have you ever been convicted of any violation of law other than minor traffic violations?
Yes
No
If Yes give date, place of conviction, charge and disposition of each case. NOTE: A conviction record may bar you from membership as per the policies set forth in our constitution and bi-laws