Application
Name:*
Primary Phone:*
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Other Phone:
-
Driver's License Number:*
Birth Date:*
Department member referral (if applicable):
Address:*
Position Applied For: (Check All That Apply)*
E-mail:
Employer:*
Employer Address:
Position*
Employer Phone:
-
Fire Fighting or EMS experience?*

If you answered yes, please fill out the following information.  If you answered no, please click "Education" to move on in the application.

Certifications Held:
Department / Company
PSID:
High School:*
Diploma / GED:*
Years Attended:*
Did you serve in the military?*

If you answered "Yes", please fill out the following information.  If you selected "No", please click "Other Information" to move on in the application.

Branch:
Rank:
Total years of service:
Skills / Duties:
Have you ever been convicted of a crime other than a minor traffic violation?*
If yes, please explain:

EMPLOYMENT APPLICATION CONSENT RELEASE: BACKGROUND CHECK

By selecting "Yes" below,

I hereby certify that the facts set forth in the completed employment application are true and complete to the best of my knowledge.  I understand that if employed, falsified statements on this application may result in dismissal.  I release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization, as well as form liability that might otherwise result from the request or use of and/or disclosure of any or all foregoing information.  You are hereby authorized to make any investigation of my personal history, academic/professional credentials, military service, criminal or driving records.

Consent:*
Verification: