SERGEANT BLUFF FIRE DEPARTMENTMembership Application

APPLICANT INFORMATION

_________________________________ _________________________________ _____ Last Name First Name MI

_________________________________ _______________ _____________________ ____ _________ Street Address Apartment/Unit # City State Zip

___________________________ ___________________________ ___________________________ Home Work Cell

__________________________________________________________Email

_________________________________ _________________________________ Date of Birth Social Security No.

_________________________________ _________________________________ IA Drivers License Expiration Date

YesAre you a citizen of the United States? No

EMERGENCY CONTACT

_________________________________ _________________________________ Name Relationship

___________________________ ___________________________ ___________________________ Home Work Cell

CURRENT EMPLOYMENT INFORMATION

_________________________________Employer

_________________________________ ________________________ ____ _______ Address City State Zip

_________________________________ _________________________________ Supervisor Name Phone Number

_________________________________ _________________________________ Job Title Work Hours

PRIOR EMPLOYMENT INFORMATION

_________________________________Employer

_________________________________ ________________________ ____ _______ Address City State Zip

_________________________________ _________________________________ Supervisor Name Phone Number

______________________________________________________________________________________________Reason for Leaving

APPLICANT ACKNOWLEDGEMENTI hereby request membership on the Sergeant Bluff Volunteer Fire Department. I understand that if I am elected to the department that I will undergo a one-year probationary period during which my role at emergency calls will be limited. During this peiod I will be expected to participate in the regularly-scheduled trainings and meetings as required by the Department bylaws. My progress will be evaluated at the end of the one year period for determination of full membership to the department.

By signing this applicaiton, I agree to abide by the by-laws, administrative policies, and operational guidelines of the Sergeant Bluff Fire Department. I further agree to obey all lawful orders from the officers and command staff of the Sergeant Bluff Fire Department.

I hereby certify that all statements in this application are true. I understand that any untrue statements may cause this application to be rejected and/or any appointment to a position rescinded. I understand the Sergeant Bluff Fire Department will conduct searches of the Sex Offender Registry, scan for local and/or state criminal history, review my driving record, and search for any outstanding warrants. I hereby authorize the Sergeant Bluff Fire Department to conduct these searches and associated activity as well as to contact any of the employers listed.

OFFICIAL USE ONLY

FIRE DEPARTMENT INFORMATIONPosition applying for: Firefighter Ambulance (check all that apply)Why are you interested in becoming a member of this department?

______________________________________________________________________________________________

______________________________________________________________________________________________

List any physical or mental health issues that may limit your ability to perform fire department duties:

______________________________________________________________________________________________

______________________________________________________________________________________________

List any prior experience or training (including department name) in fire fighting, resuce, or EMS:

______________________________________________________________________________________________

______________________________________________________________________________________________

List any current certifications held (Firefighter I, CPR, EMT-B, etc.):

______________________________________________________________________________________________

______________________________________________________________________________________________

_________________________________ _________________________________Signature Date

Fire Department Chief DateCity Council/Mayor DateSex Offender Registry Check DateDriving Record Check DateOutstanding Warrant Check DateCriminal History Check DatePhysical Agility Date