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Membership Application
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APPLICATION FOR MEMBERSHIP
This application is for volunteer membership. Paid positions are posted on the City of Deer Park's job openings page.
***********************************************
Service Applying For
*
Volunteer Firefighter
Volunteer EMS provider
Volunteer Firefighter and EMS provider
First Name
*
Last Name
*
Address1
*
City
*
State
*
Zip
*
Date of Birth
*
Date of Birth
Place of Birth
*
Sex
*
-- Select One --
Male
Female
Social Security Number
*
Phone Number
*
Email
Texas Drivers License Number
*
Type of License
*
-- Select One --
A
B
C
Marital Status
*
Single
Married
Divorced
Spouses Name
*
(N/A if not applicable)
Children
*
Number (N/A if not applicable)
EMPLOYMENT
Current Employer
*
Phone Number
*
Current Position
*
Type of Schedule
*
Address1
*
City
*
State
*
Zip
*
Previous Employer
*
(N/A if not applicable)
Address
*
(N/A if not applicable)
Phone Number
*
(N/A if not applicable)
Previous Employer
*
(N/A if not applicable)
Address
*
(N/A if not applicable)
Phone Number
*
(N/A if not applicable)
EDUCATION
High School
*
Graduated
*
-- Select One --
Yes
No
Degree
*
-- Select One --
Diploma
GED
Did Not Graduate
Address
City
*
State
*
College
*
(N/A if not applicable)
Graduated
*
-- Select One --
Yes
No
N/A
Degree
*
-- Select One --
N/A
Certificate
Associate's
Bachelor's
Graduate
Certificate/ Major
*
(N/A if not applicable)
Address
City
*
(N/A if not applicable)
State
(N/A if not applicable)
Fire Certification(s)
*
(N/A if not applicable)
EMS Certification(s)
*
(N/A if not applicable)
CRIMINAL HISTORY
Have you ever been convicted of a crime, excluding traffic violations
-- Select One --
Yes
No
If yes, please explain
*
(N/A if not applicable)
PHYSICAL HISTORY
Do you have any of the following?
*
Heart Disease
Epilepsy
Emphysema
Asthma
Diabetes
Other
N/A
Do you have any impairments with
*
Hearing
Eyesight
N/A
If you checked other, please explain
*
(N/A if not applicable)
The City of Deer Park Volunteer Fire Department will not accept physical examination papers from other physicians. The City of Deer Park Physician must examine all applicants.
REFERENCES
Name
*
Address
*
Phone Number
*
Name
*
Address
*
Phone Number
*
Name
*
Address
*
Phone Number
*
By typing your name below you are certifying that all statements in this application are true to the best of your knowledge and understand that any falsification of records on this document will void any connection between yourself and the City of Deer Park Volunteer Fire Department. Additionally, by typing your name below you are consenting to a drug test and commiting to abide by the City of Deer Park's Policies on Acohol and Drug Abuse.
Name
*
(First and Last)
Date and Time of Application
*
Date and Time of Application
Date and Time of Application
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