Position Applied for: Volunteer Firefighting Volunteer Non-Firefighting Name Address Phone Email How long have you lived in Colusa? Health Excellent Good Fair Poor Marital Status Single Married Separated Divorced BRANCH OF MILITARY (If Applicable) Navy Marines Air Force Army Dates of Service: Type of Discharge Honorable General Dishonorable Are you a member of the National Guard or Reserve? Yes No Highest Grade Completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Name and Address of High School Date Graduated: Technical School Attended and Dates College or Universities Attended Present Employer Address Occupation Immediate Supervisor and Contact Info May we contact this Employer? Yes No Previous Employer Address Occupation Immediate Supervisor and Contact Info May we contact this Employer? Yes No 1) Name of Reference Phone Number 2) Name of Reference Phone Number 3) Name of Reference Phone Number Have you ever been a member of a Fire Department, Rescue Squad, or any other similar organization? Yes No Name and Address of Organization Dates of Service Position Held Reason for Leaving List all related training you have completed In a brief paragraph, state why you wish to join the Colusa Fire Department. What the Department can gain from your membership. What do you expect to gain from your membership. Have you ever been dismissed from any position? Yes No If yes, Explain Have you ever been forced to resign from any position? Yes No If yes, Explain Have you ever been arrested, summoned into court as a defendant or indicted, convicted, fined, imprisoned, or placed on probation, or has any case been filed against you? Yes No If yes, Explain In the event of my Membership by the Colusa Fire Department, I agree to abide by all present and subsequently issued rules of the Fire Department. authorize all schools which attended and all previous employers to furnish to the Colusa Fire Department my record, reason for leaving, and all information they may have concerning me. I hereby release them and the Colusa Fire Department from all liability for any damage whatsoever arising therefrom. I also authorize investigation of all statements in this application. I understand that, in the event of my membership by the Fire Department, any misrepresentation or failure to give material information shall constitute misconduct and just cause for my dismissal as a volunteer member of the Colusa Fire Department. Date By typing your full name, you agree to the terms above Submit
