Zumbrota Fire Department - Member Application

Name *

Phone Number: *

Are you legally authorized to work in the U.S.? * Yes
No

Do you have any physical limitations, which would restrict your ability to perform firefighting duty's? * Yes
No

If yes, please explain:

Do you have any commitments or responsibilities that might prevent you from meeting job requirements? * Yes
No

Do you have any relatives on the Fire Department? * Yes
No

If yes, who?

Education & Training

High School *

Did you graduate? * Yes
No

College/Trade School:

Subject Major

Did you earn your degree? Yes
No

Please list any education/training which you feel can relate to this position: *

Have you received Firefighter training in the past? * Yes
No

Type of Firefighter training & date completed:

Have you received CPR/first aid training? * Yes
No

Date last certified:

Are you willing to attend classes to obtain state level certification of Firefighter I, II, and Hazmat? * Yes
No

Driving Record

Do you hold a valid drivers license? * Yes
No

Drivers License #:

Do you have truck driving experience? * Yes
No

Type of Vehicle:

Endorcements:

Availability

What hours are you available to respond to emergency calls? *

Are you able to attend training and business meetings on the 2nd and 3rd Monday evening of each month? * Yes
No

Approximate amount of time (in minutes) from your home to the Fire Station: *

Approximate amount of time (in minutes) from your place of employment to the Fire Station: *

Current Employment

Present Employer: *

Job Title: *

Supervisor's Name: *

Phone Number: *

Hire Date:

Total Years Employed:

Typical working hours:

Specific duties: *

Does business take you out of town? * Yes
No

If yes, please explain:

Would your employer allow you to leave work during emergency calls? * Yes
No

Special Skills & Qualifications

Summarize any special job-related skills and/or qualifications acquired from employment or other experiences: *

Please list any volunteer, professional, trade civic activities and offices held: *

Military Experience

Have you ever served or trained in the the U.S. Armed Forces? * Yes
No

Branch of Service, Highest Rank, & Pay Grade:

Dates of Active Military service:

Entry:

Separation:

Please explain if Dishonorable or other:

Are you presently a member of the U.S. Military Reserve or National Guard? * Yes
No

Branch of Service, Highest Rank, & Pay Grade:

Please list any Military Training/Jobs:

References

Name *

Phone Number: *

Name *

Phone Number: *

Name *

Phone Number: *

I certify that the statements made by me on this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that if I knowingly made a misstatement of these facts, I am subject to rejection and/or removal as a member of the Zumbrota Fire Department. I am agreeing to a probationary status pending successful completion of Firefighter I, II, and Hazmat training which the Zumbrota Fire Department will provide.

By checking yes below, you are agreeing to the above statement. * Yes
No