Application

Name *

First

Last

Birthdate *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Work Phone

Email *

Do you have a current Colorado driver's license? *

Yes
No

Driver's License Number *

State of license Issue *

License Expiration Date *

Social Security Number *

Employment

Please list your last two employers, or your employer for the last five years.

Occupation *

Employer *

Employer Address *

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor *

Employer Phone *

Work Shift *

(Weekdays only, nights, weekends, shifts, etc.)

Beginning Date of Employment *

Are You Currently Employed There? *

Yes
No

Ending Date of Employment *

Can You Leave Your Job to Respond to an Emergency Call? *

Yes
No

Would You Like To Enter Another Job? *

Yes
No

Previous Employment

Occupation *

Employer *

Employer Address *

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor *

Employer Phone *

Work Shift *

(Weekdays only, nights, weekends, shifts, etc.)

Beginning Date of Employment *

Ending Date of Employment *

Previous Experience

Do You Have Any Previous Fire Department And/Or Emergency Medical Experience? *

Yes
No

Agency Name *

Agency Address *

Address Line 1

Address Line 2

City

State

Zip Code

Position *

Supervisor *

Agency Phone *

Beginning Date *

End Date

(Leave this blank if you are still with the agency)

Would You Like To Enter Additional Fire Department And / Or Emergency Medical Agency Experience?

Yes
No

Additional Fire Department And / Or Emergency Medical Agency Experience

Agency Name *

Agency Address *

Address Line 1

Address Line 2

City

State

Zip Code

Position *

Supervisor *

Agency Phone *

Beginning Date *

End Date

Personal Information

How Long Have You Lived in the Colorado Springs Area? *

Marital Status *

Single
Married

Spouse's Name *

Next of Kin *

Relationship *

Next of Kin Phone *

Next of Kin Address *

Address Line 1

Address Line 2

City

State

Zip Code

Education

High School Name *

Did You Graduate? *

Yes
No

Year of Graduation *

Did You Receive Your GED? *

Yes
No

College Name

Course

Did You Graduate?

Yes
No

Degree

College Name

Course

Did You Graduate?

Yes
No

Degree

Are You EMT Certified? *

Yes
No

State of Certification *

Expiration of Certification *

Other Fire or Medical Training

Medical

Sex *

Male
Female

Height *

Weight *

Blood Type *

Eye Color *

Hair Color *

Allergies

Do you have any physical conditions, medical history, or history of mental conditions which could limit your performance as a firefighter or medical care provider? *

Yes
No

Please describe the condition or medical history *

Legal

Have You Ever been Convicted of a Felony? *

Yes
No

Please Describe *

Signature

I specifically grant the Donald Wescott Fire Protection District permission to obtain my driving record and my criminal history. If accepted as a member it will be necessary to supply the fire department with my Social Security number and Driver's License number. Further, I certify that all of the information furnished on this form is true, complete, and correct to the best of my knowledge. I understand that all information is subject to verification by the Donald Wescott Fire Protection District. False information is cause for rejection of application.

Signature *

Typing your full name here constitutes a legal signature.

Date *

Application

Donald Wescott Fire Protection Disctrict Application for Volunteer Membership

Employment

Previous Employment

Previous Experience

Additional Fire Department And / Or Emergency Medical Agency Experience

Personal Information

Education

Medical

Legal

Signature