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I am interrested in: (check all that apply)
MI
Ages 14 - 18
Thank You for wanting to join our Fire Team.
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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?
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No
College Attended
Major course of study
Degree Earned
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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
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