Alamosa Fire Department Application for Membership

The Alamosa Volunteer Fire Department is an Equal Opportunity Organization and will consider all applications without regard to race, marital status, sex, age, color, religion, national origin, veteran status, disability or any other characteristic protected by law. It is our intention that all qualified applicants are given equal opportunity and that selection decisions are based on membership and volunteer position factors. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon volunteer position information.

Application

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Applicant Information

Full Name (First Middle Last)

Street Address

Street Address Line 2

City

State

Postal / Zip Code

Email

Phone (###-###-####)

Do you live within Alamosa city limits?

Yes

No

Have you previously applied for membership with Alamosa Fire Department?

Yes

No

If Yes, give month & year.

Are you 19 years of age or older?

Yes

No

How did you hear about membership opportunities?

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Education: High School or GED

Name of School

Course of Study

No. of Years Completed

Degree or Diploma

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Education: Business/Trade

Name of School

Course of Study

No. of Years Completed

Degree or Diploma

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Education: College

Name of School

Course of Study

No. of Years Completed

Degree or Diploma

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Employment: Please give accurate, complete full-time and part-time employment history including military service. Start with your present or most recent employer FIRST. If self-employed, give firm name and business references. If necessary, attach additional sheets using the same format. NOTE: Membership may be contingent on acceptable references from current and former employers.

1) Company Name

Phone Number

Addresss (Street, City, State, Zip)

Dates Employed

Name of Supervisor

Reason for Leaving

Job Title & Duties

2) Company Name

Phone Number

Addresss (Street, City, State, Zip)

Dates Employed

Name of Supervisor

Reason for Leaving

Job Title & Duties

3) Company Name

Phone Number

Addresss (Street, City, State, Zip)

Dates Employed

Name of Supervisor

Reason for Leaving

Job Title & Duties

Have you been fired from a job or asked to resign in the last 10 years?

Yes

No

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Current Certifications

Please Check Any that Apply

Firefighter One Level of State Qualification

Firefighter Two Level of State Qualification

Colorado EMS First Responder

Emergency Medical Technician - Basic

Hazmat Operations level of State Certification

Hazmat Technician level of State Certification

CPR

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Certification Expiration Dates

Firefighter One Level of State Qualification

Firefighter Two Level of State Qualification

Colorado EMS First Responder

Emergency Medical Technician - Basic

Hazmat Operations level of State Certification

Hazmat Technician level of State Certification

CPR

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Skills & Proficencies

List proficiency with any heavy machinery, industrial equipment, or specialized training you may have.

List any computer skill you may possess ,i.e., hardware, software applications, programming skills, etc.

Do you have a valid driver's license?

Yes

No

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References: Give three references, not relatives, who have definite knowledge of your business or professional qualifications for the position of volunteer firefighter. Do not repeat names of supervisors listed under employment history.

Reference 1 (Name & Phone)

Reference 2 (Name & Phone)

Reference 3 (Name & Phone)

Upload Resume

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Affidavit

Please read each statement carefully and acknowledge by checking each box before signing.

I certify that all information provided in this membership application is true and complete. I understand that any false information or omission may disqualify me from further consideration for membership and may result in my dismissal if discovered at a later date.

I understand that the Alamosa Fire Department may request an investigative consumer report from a consumer-reporting agency. This report may include information as to my character, reputation, personal characteristics, and mode of living obtained from interviews with neighbors, friends, former employers, schools, and others. I understand I have the right to make a written request within a reasonable time for disclosure of the nature and scope of the investigation.

I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employers (except as previously noted), past employers, and organizations named in this application to provide relevant information and opinions that may be useful in making a membership decision. I release such persons and organizations from any legal liability in making such statements.

I understand that if I am extended an offer of membership will be conditioned upon my successfully passing a complete pre-engagement physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capacity to do the work for which I am applying.

I understand that if I am extended an offer of membership, I will be required to successfully pass a drug screening examination. I hereby consent to a pre-engagement drug screen as a condition of membership.

I UNDERSTAND THAT THIS APPLICATION FOR MEMBERSHIP DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR DOES ANY OFFER OF MEMBERSHIP GUARANTEE MEMBERSHIP FOR ANY DEFINITE PERIOD OF TIME.

I have read, understand, and by my signature consent to these statements.

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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