First Name:      Last Name:      Middle Initial:

Social Security Number:      Birth Date (MM/DD/YYYY):

E-mail:      Work Phone:      Home Phone:

Current Address: Street Address Address (cont.) City State/Province Zip/Postal Code How long did you live here? years

Previous Address: Street Address Address (cont.) City State/Province Zip/Postal Code How long did you live there? years

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Medical Data

Height Weight Hair Color Eye Color		Blood Type Corrective Lenses (Required) If yes ...   Yes  No Eye Glasses Contacts
Are you currently taking any prescribed medications?  If so, please list.
Any know allergies?
Last complete physical (MM/DD/YYYY)		Last tetanus shot (MM/DD/YYYY)
Do you have any existing medical condition(s) that would interfere with your ability to perform the duties as a member of this department? These duties include, but are not limited to, firefighting and rescue work including training (active members only), heavy lifting, driving fire apparatus, climbing ladders, working fund raising events, public service details and general department cleanups. If so, please list:

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Education

	Name	Location	Years	Date Graduated (MM/DD/YYYY)
High School
College
Trade School

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Employment History

Current Employer

Name		Occupation
Address
Contact Person
Employed from (MM/DD/YYYY)		To (MM/DD/YYYY)

Previous Employer

Name		Occupation
Address
Contact Person
Employed from (MM/DD/YYYY)		To (MM/DD/YYYY)

Previous Employer

Name		Occupation
Address
Contact Person
Employed from (MM/DD/YYYY)		To (MM/DD/YYYY)

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References

Name
Address
Home Phone		Work Phone

Name
Address
Home Phone		Work Phone

Name
Address
Home Phone		Work Phone

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General Information

Drivers License (for insurance purposes only)

State      Number
Class      Expires (MM/DD/YYYY)
Has your license ever been suspended? (Required)           Yes  No
If yes, why?
Have you ever been convicted of a crime? (Required)           Yes  No
If yes, please provide details.

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Fire and Rescue Experience

Are you presently a member of any fire, rescue or EMS department? (Required)              Yes  No
If yes, give the department names and contact persons of any departments you previously belonged to.
Name Contact
List the types of fire/rescue vehicle(s) you have driven (ambulance, engines, ladder trucks).
List any fire/rescue/EMS courses you have taken including where and when.

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Signature

Please read the following statement carefully.

Holiday Park Volunteer Fire Department is an equal opportunity organization. We do not discriminate against applicants based on race, religion, sex, color or ethnic origin.

By submitting this application I hereby authorize the Holiday Park Volunteer Fire Department to investigate all statements contained within this application. To the best of my knowledge, all statements and answers which I have given are true, accurate, and correct. I understand that misrepresentation or omission of facts may result in nullification of this application or subsequent membership based upon its contents. I further affirm that if accepted, I will abide by all rules, regulations, policies, motions, and by-laws of the Holiday Park Volunteer Fire Department.

Please type your name in the space provided to confirm that you have read and understand.

(Required to apply)