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Application for Membership

(Please print out this form, fill it out completely, and then mail to the address below or give to any officer of the Strasburg Fire Department)

Date of Application:__________________   Date to Probation__________________________

 

Personal Information:

Name:____________________________________     Age in Years:___________________

Date of Birth:_______________________________     Place of Birth:___________________

Marital Status:______________________________     Number of Children:______________

Social Security Number:_______________________

Colorado Driver's License Number:____________________________ Exp:______________

 

Height:____________  Weight:____ _________  Hair:_____________  Eyes:_____________

 

Residence Information:

Current Address:___________________________________________________________________

How long at present address?___________

Home Phone:__________________________  Work Phone:__________________________

Emergency Contact:____________________  Relationship:__________________________

Phone:__________________________________

 

Employment History:

Present Employer & Address:__________________________________________________

Number of Years or Months:_________________

Position:______________________________  Phone:_______________________________

 
 

Education History:

High School Attended:__________________________  Year Graduated:_________________

College Attended:_______________________________ Degrees:_______________________

List any courses of special training in Fire, EMS, and/or HazMat

_____________________________________________________________________________

_____________________________________________________________________________

 

Armed Service History:

Service Branch:__________________________  Dates Served:_________________________

Type of Discharge:_______________________   Date of Discharge:_____________________

 

Medical History:

Check any of the following limitations that may apply to you:

_______

Missing Appendage

_______

Muscular Cramps

_______

Diabetes

_______

Drug Addiction

_______

No Sense of Smell

_______

Nervous Disorder

_______

Back Pain / Spasms

_______

Stiff Bone or Joint

_______

Corrective Lens Wearer

_______

Claustrophobia

_______

Circulatory Problems

_______

Hearing problems

_______

Far-Sighted

_______

Hypertension

_______

Near-Sighted

_______

Alcohol Addiction

_______

Speech Problems

_______

Hernia

_______

Heart Problems

_______

Severe Sinus Condition

_______

Asthma

_______

Allergies _______________________________

_______

Other:________________________________

 

 

 

Do you receive any daily medication?_____ If so, list:________________________________

Have you ever been on medical disability or compensation? If yes, list:

____________________________________________________________________________

 
 

Previous Experience:

Name of Organization:________________________________________________________________

Address:____________________________________________________________________

Job Title:__________________________  Duties:__________________________________

Years of Service: (from)_____________________ (to)_________________________

 

Name of Organization:________________________________________________________________

Address:____________________________________________________________________

Job Title:__________________________  Duties:___________________________________

Years of Service: (from)_____________________ (to)_________________________

 

Name of Organization:________________________________________________________________

Address:____________________________________________________________________

Job Title:_________________________  Duties:___________________________________

Years of Service: (from)_____________________ (to)_________________________

 

Do you have any of the following:

_____  First Responder Certificate             Exp. __________

_____  CPR Card                                        Exp. __________

_____  EMT  what level _____                  Exp. __________

_____  IV Certification

_____  Fire Fighter I

_____  Fire Fighter II

_____  HazMat    what level ___________________

 

 

What is your interest in the department?

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

 

I understand as a member of the department:

·         Obtain and keep updated a CPR card, at least a First Responder Certificate and Haz MAT Operations level certified within probation.

·         Agree to abide by the By-Laws, Rules, and Regulations of the Department.

·         Obtain 36 fire training hours, 8 HazMat training hours, and 8 medical training hours as an active full member, or obtain 36 medical training hours, 8 HazMat training hours and 8 Rescue training hours as an EMS only member.

·         Serve the Department on clean-up detail as necessary.

·         Pass a medical physical equivalent to a DOT physical as a prerequisite to becoming a member of this department.

·         Provide current DMW of your previous 3 years is also required along with application.

·         Agree to a background check.

·         Attend and complete an orientation class.

 

If this application is accepted, you will serve a six-month to twelve-month probationary term and you may be rejected at the end of that term.

This application is subject to investigation and verification and that the Department reserves the right to consult with references, employers and military personnel.

To the best of my knowledge, the above and preceding questions have been answered truthfully.

I do here-by authorize the release of my personnel files to the Strasburg Volunteer Fire Department and Rescue Squad at their request.

Signature:_______________________________  Date:_______________________________

(C) 1999 SVFD

Strasburg Volunteer Fire Department
PO Box 911
Strasburg, CO  80136
(303) 622-4444

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