Volunteer Firefighter Application

Full Name: (Last, First, Middle)

Address: (Physical)

Address: (Mailing)

Home Telephone:

Work Telephone :

Social Security Number:

Date of Birth:

Drivers License Number:

State:

Class:

How long have you lived in this community?

Have you ever been convicted of ANY crime?

Yes No

Have you ever had your drivers license suspended or revoked?

Yes No

Nickname or alias

Education and Training:

High School

Graduate?

YesNo

Highest Grade Completed:

College/University

Graduate?

YesNo

Highest Grade Completed:

Tech/Trade School

Graduate?

YesNo

Number of Years Attended:

Other:

Medical:

1. Have you ever had heart trouble or ever been told that you had trouble with your heart?	Yes No
2. Have you ever been treated for high blood pressure or ever been told that your blood pressure is not normal?	Yes No
3. In the past 5 years have you been hospitalized overnight for any reason?	Yes No
4. In the past twelve months have you seen a doctor for anything other than routine checkups?	Yes No
5. Have you experienced prolonged shortness of breath?	Yes No
6. Have you ever had allergies (asthma, hayfever, bronchitis, eczema), diabetes, stroke, eye trouble (other than glasses), or hearing deficit?	Yes No
7. Are you now or have you ever been released from employment because of a work related injury?	Yes No
8. Do you have any physical problems/ limitations that might impair your ability to lift, walk, run, climb, stand, jump, or complete a physical agility course? If so, check the appropriate activities below that might be impaired.	Yes No

Lift

Walk

Run

Climb

Stand

Jump

Physical Agility Course

Additional Information:

Have you ever been a member of this company or any other volunteer company before?

Yes No

Position/Rank held

Do you have any friends or relatives in this company?

Yes No

Military Service?

YesNo

Branch

Rank

Dates

Current Employment:

Business Name
Address
Business Telephone
Dates of Employment

Is your employer aware of your desire to participate in our community as a volunteer firefighter, and will you be allowed to respond to emergency calls during working hours?

Yes

Comments

Most Recent Past Employment:

Business Name
Address
Business Telephone
Dates of Employment

References:

Name:
Address:
Telephone:
Relationship:
Name:
Address:
Telephone:
Relationship:

Why Do You Want to Become a Volunteer Firefighter? Please comment in space below:

List Any Previous Firefighting Training/Experience Please comment in space below:

List Any Special Skills, Education, Abilities, or Training Please comment in space below:

Affidavit

By submitting this application for volunteer firefighter, I hereby certify and declare that all statements given by me on the application form are truthful and complete statements to the best of my knowledge. I understand that any willfully false or incomplete information contained on my application form will be just cause for immediate rejection or expulsion from Westlake Fire Department.

I understand that my standing in Westlake Fire Department may be contingent upon taking and passing a medical examination, a thorough background check, and a physical performance test. I also understand that I will serve a probationary period. I understand that I may be photographed and finger printed to fulfill certain licensing requirements.

I hereby authorize any and all persons having information concerning me, either of public record or otherwise to furnish it to a duly authorized agent of the Westlake Fire Department and/or the Calcasieu Parish Sheriff's Department, Lake Charles, Louisiana and I release them from all liabilities or damage arising because of furnishing such information.

Applicant Name:
Date of Application: