Firefighter Application

First:

Middle:

Last:

Present Address

Street Number & Name:

City:

State:

Zip:

Years: Months:

Home:

Work:

Cell:

Enter email address:

Confirm email address:

I am able to respond to incidents during: Day Night

Between the hours of and

I will be responding from my place of employment

I am able to obtain written authorization to respond from my employer

(Provide copies of diploma, GED, certifications, etc...)

Are you an Armed Forces Veteran Yes No

Are you currently under indictment for a felony warrant(s) Yes No

Have you ever been convicted of a felony Yes No

Have you ever been arrested, detained, or taken into custody in this state, in any other state, in military service, or elsewhere for a felony or a misdemeanor; or were you ever investigated by a law enforcement or governmental agency? Yes No

Do you possess a means of reliable transportation? Yes No

Has your driver's license ever been suspended or revoked Yes No

Have you ever been involved in an accident Yes No

Are you able to perform the following tasks with or without accommodation?

Climbing: Yes No

Lifting: Yes No

Wearing of Breathing Apparatus: Yes No

Do you currently possess Michigan Firefighters Training Council Certificates for Firefighter I & II: Yes No

How did you hear about becoming a volunteer firefighter? (Check all that apply)