Fire Department Volunteer Application

Personal Information

Date

Name

First

Last

are Personal reference?

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Phone

General Questions

Are you a citizen of the United States?

Yes
No

If no, are you authorized to work in the US?

Yes
No

Have you ever been convicted of a felony?

Yes
No

If yes, please explain:

Education

High School Name

Did you graduate?

Yes
No

Additional Education — Please list:

Driving Record

Driver's License Number

Issuing State

Expiration Date

License Class

Endorsements

Have you had any moving violations in the last 5 years?

Yes
No

If yes, please list violation(s) and date(s):

Have you had any vehicle accidents in the last 7 years in which you were partially or fully at fault?

Yes
No

If yes, please list accident(s) and date(s):

Have you ever had a driver's license suspended or revoked?

Yes
No

If yes, please list date(s) and circumstances:

Desired Position

What type of volunteer are you seeking? (Check all that apply)

Current Employment

Employer Name

Job Title / Position

Address

Phone Number

Responsibilities

Starting / Ending Dates

May we contact your current employer for a reference?

Yes
No

References

Please list 3 references including Full Name, Relationship, Company, Address and Phone Number:

Authorization & Certification

I authorize the City of Girard to conduct a background check / driver's license check through the Kansas Department of Revenue, Divisions of Vehicles. I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Driver's License #

Authorization

I authorize the City of Girard to conduct a background check / driver's license check through the Kansas Department of Revenue, Divisions of Vehicles.

Electronic Signature

Type your full name.

Certification

I certify all information provided is true and accurate

Date