Woden Fire Dept. Application

MEMBERSHIP APPLICATION

Please fill out the application below to the best of your ability and submit it.
A member of the department will be in contact with you as soon as possible.
The member that contacts you will give you all the neccessary information for joining the fire department. We have 3 classes of voting members at Woden - Firefighter, 1'st Responder, and Rehab. We appreciate your interest in becoming a member of our department.

CONTACT INFORMATION

Name:

Address:

Phone:

Cell:

email:

GENERAL

Date of birth:

DL#:

Do you have any moving violations on your record for the past three years?(please list)

Have you ever been convicted of a felony? (If you answered yes, please explain)

Do you hold a valid EMS certification? If you answered yes, what is it?

Have you ever belonged to another fire department? Please list:

Who recommended the Woden Fire Department to you?

MEDICAL INFORMATION

Who is your doctor? What hospital do you use?

What medications are you currently taking?

Please list ALL allergies.

Please list your past medical history.

REFERENCES

Name: Phone:

Name: Phone:

Name: Phone:

Best way to contact you? (please select from the box below)

To submit this application, please click on the submit button below. By clicking on the submit button, you are verifying that all information that you have supplied is true and accurate to the best of your knowledge. Also by submitting this application you are giving the Woden Fire Department permission to do a background check on you and you may be required (at the expense of the Woden Fire Department) to submit to a drug test.

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