Confidential Application

Today's Date

Personal Information

Full Name

Date of Birth

Mailing Address

Physical Address

Phone Number

Driver's License Number

Driver's License State/Class

Driver's License Expiration

General Information

Do you have previous firefighting experience? (If yes, explain)

List any certifications you have:

Do you have other experience, skills, or qualifications which you think would benefit our department?

Are you able to attend 75% of the meetings required by our Bylaws on the 1st and 3rd Wednesday of each month?

Yes

Are you able to leave work for emergency calls?

Yes

Have you ever been convicted of a crime? If yes, please explain. Include data, place, and nature of crime.

Employment History/References

List your most recent position first

(1) Employeer

(1) Supervisor

(1) Poisiton/Duties

(1) Address

(1) Phone

(1) State Date/ End Date

(1) Reason for leaving

(2) Employeer

(2) Supervisor

(2) Poisiton/Duties

(2) Address

(2) Phone

(2) State Date/ End Date

(2) Reason for leaving

(3) Employeer

(3) Supervisor

(3) Poisiton/Duties

(3) Address

(3) Phone

(3) State Date/ End Date

(3) Reason for leaving

Person References (Do not list former employers or relatives)

Reference 1 Name

Reference 1 Address

Reference 1 Phone

Reference 2 Name

Reference 2 Address

Reference 2 Phone

Reference 3 Name

Reference 3 Address

Reference 3 Phone

Tell us why you want to join the Thayne Fire Department:

I hereby certify that the answers given by me to foregoing questions and all statements made by me herein are true and correct to the best knowledge and belief.

I have read and undertand the following:

Attendance Policy

Pension Policy

Department Bylaws

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