Employment/Membership Application

    Applicant Information

    First Name

    Last

    M.I.

    Street Address

    Apartment/Unit #

    City

    State

    ZIP

    Phone

    E-Mail Address

    Cell Phone

    Social Security No.

    Date of Birth

    Marital Status

    Spouse's Name

    TDL

    Type

    Exp

    Date Available to Start

    Have you ever been refused admittance to or been discharged from any Fire or EMS Service?

    If yes, explain

    Have you ever been arrested?

    If yes, explain

    Emergency Contact

    Phone

    Relationship

    Education

    High School

    City,State

    Did you Graduate?

    Bilingual

    Languages

    College

    City,State

    Certification

    Cert #

    EXP

    Certification

    Cert #

    EXP

    Upload File Here (please upload only .jpg or .pdf)

    References

    Full Name

    Relationship

    Company

    Phone

    Address

    Full Name

    Relationship

    Company

    Phone

    Address

    Full Name

    Relationship

    Company

    Phone

    Address

    Previous Employment

    Department

    Phone

    Address

    Years with Department

    Responsibilities

    Employment From

    Employment To

    Reason for Leaving

    May we contact your previous supervisor for a reference?

     

    Department

    Phone

    Address

    Years with Department

    Responsibilities

    Employment From

    Employment To

    Reason for Leaving

    May we contact your previous supervisor for a reference?

     

    Department

    Phone

    Address

    Years with Department

    Responsibilities

    Employment From

    Employment To

    Reason for Leaving

    May we contact your previous supervisor for a reference?

     

    Military Service

    Branch

    Service From

    Service To

    Rank at Discharge

    Type of Discharge

    If other than honorable, explain

    Disclaimer and Signature

    I, the undersigned, certify the foregoing information to the true and correct to the best of my knowledge and belief and agree that any false statements are ground for my immediate dismissal. I further agree to bide by the By-Laws of the Westlake Volunteer Fire Department and follow all rules, regulations, policies, and procedures. It is also understood that all information in this application will be investigated.

    Signature

    Date