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Membership Application

Online Application.
 Applications are currently being taken for membership. 
Contact the Strasburg Fire Protection District Office at 303-622-4814
for further information or any questions.
 
 
Click the link at the bottom of the page for a Microsoft Word version of the Document.
 
 
 
 
 
 

STRASBURG FIRE PROTECTION DISTRICT NO. 8

 

APPLICATION FOR MEMBERSHIP

 

 

Personal Information                                     Date of Application: _____________

 

Last Name:  __________________                            

 

First Name: __________________                             Middle Initial: _______

 

Do you have any other names you have been referred to as, maiden names, names used in online social networking sites, blogs, online gaming: If so please list: ________________

________________________________________________________________________

 

Social Security No. _________________       

 

Are you over the age of 18 years of age? _____________

 

Address: __________________________________________________________ 

 

City: ___________________              State: _______________         Zip Code: _________

 

Home Phone: ____________________           Cell Phone: ___________________   

 

Email Address: _____________________________________

 

Employment History

 

Current Employer: _______________________________________________

 

Employer Address: ______________________________________________

 

City: ___________________              State: _______________         Zip Code: _________

 

Dates of Employment:   From: __________________ To: _________________

 

Your title: _____________________________________

 

Your duties: _____________________________________________________________ _______________________________________________________________________

 

Supervisor’ Name: __________________________   Phone No. _________________

 

May we contact your current supervisor                        Yes ________     No  ________

 

Previous Employer: _______________________________________________

 

Employer Address: ______________________________________________

 

City: ___________________              State: _______________         Zip Code: _________

 

Dates of Employment:   From: __________________ To: _________________

 

Your title: _____________________________________

 

Your duties: _____________________________________________________________ _______________________________________________________________________

 

Supervisor’ Name: __________________________   Phone No. _________________

 

May we contact your previous supervisor                      Yes ________     No  ________

           

Reason for leaving: _______________________________________________________ _______________________________________________________________________

 

Education

 

High School Attended: __________________________ Year Graduated: ____________

 

GED Acquired From: ________________________

 

College Attended: ______________________________        Degree ________________

 

Years Attended: _______________________

 

List any course of special training in fire, EMS and/or Haz Mat: ___________________

________________________________________________________________________

 

Driving History                     

 

Drivers License No. _______________  State: _____________ Expiration ___________

 

Have you had any moving violations:   Yes: ______   No: ______   If yes, please explain:

 

Date                 Original Charge                Final Charge                      Outcome

 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Has your license ever been suspended or revoked.  Yes: ______   No: ______   If yes, please explain:

________________________________________________________________________________________________________________________________________________

 

Legal

 

Have you ever pled guilty, no contest to, been or been convicted of a misdemeanor:

Yes: ______   No: ______   If yes, please explain:

 

Date                 Original Charge                Final Charge                      Outcome

 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Have you ever pled guilty, no contest to, been or been convicted of a felony:

Yes: ______   No: ______   If yes, please explain:

 

Date                 Original Charge                Final Charge                      Outcome

 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Firefighting and EMS Related Experience, Training and Certifications

 

                                    Expiration Date                                     Expiration Date

____ Firefighter One                _____              ____ CPR                                _____

____ Firefighter Two                _____              ____ First Responder               _____

____ Hazmat Awareness          _____              ____ NREMT – B                   _____

____ Hazmat Operations          _____              ____ EMT – B (CO)               _____

____ ICS 100, 200, 700                                  ____ NREMT – P                   _____

                                                                        ____ EMT – I (CO)                 _____

                                                                        ____ IV Approval                    _____

 

 

Please attach copies of all certifications and your MVR (Motor Vehicle Record)

 

 

 

 

 

 

Other Firefighting and EMS Related Experience, Training and Certifications

 

Type                Agency/School     Date Obtained    Certification No.    Expiration Date

 

________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Previous Fire or EMS Departments to which you have belonged:

 

Date            Department Name                                  Contact Name and   Phone.

 

________________________________________________________________________

 

References

 

Emergency Contact: _____________________           Relationship: _______ 

 

Telephone No.: ____________________

 

Please provide two references the District may contact that are not related to you.

 

1.  Name: _________________________                                                     

 

     Phone: _________________________

 

     How do you know this person: __________________________

 

2.  Name: _________________________                                                     

 

     Phone: _________________________

 

     How do you know this person: __________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT’S STATEMENT  - PLEASE READ CAREFULLY

 

I certify that all of the information and answers provided by me in this application are true and complete to the best of my knowledge.  I understand that the information contained herein may be used to determine my eligibility and suitability as a volunteer or employee with the Strasburg Fire Protection District, and that if I provided false or misleading information or if I concealed information or caused or authorized anyone else to provide false or misleading information or to conceal information in connection with my application, that it will be grounds for denial of my Application or termination my membership or employment as the case may be.

 

I give my permission for the Fire Chief or his designee to investigate and verify all of the information given by me in this Application.  I release all concerned from any liability in connection therewith. 

 

I hereby authorize the District to secure a copy of my driver’s record and I consent to a criminal background check and to provide my social security number for the purpose of conduction the criminal background check and for no other purpose.

 

I understand that neither this Application nor any offer of membership or employment from the District constitutes any employment contract unless a specific document to that effect is executed by the District’s Board of Directors as authorized at an official Board meeting.

 

I also understand that I am required to and will abide by all of the District’s rules, Standard Operating Procedures, policies and orders of the District and its officers.

 

Print Name: _______________________________

 

Signature: ________________________________

 

Date: ______________________________

ĉ
Tanner McCall,
Jan 10, 2012, 6:38 AM
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