Volunteer Form

Choose One:

Fire
EMS
Both

Name

First Middle Last

Address

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different from your home address)

Street Address Address Line 2 City State ZIP Code

Phone

Email

Are you a US Citizen?

YES
NO

Are you 18 years of age or older?

YES
NO

Date of Birth:

SSN:

Do you have a valid Driver's License?

YES
NO

License # / State / Class

How long have you been in the area? *If at current address for less than 2 years please list previous address:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Have you received any traffic citations in the last three (3) years and/or any convictions for Driving Under the Influence or Driving While Ability-Impaired during the last seven (7) years?

YES
NO

If yes, please indicate when, where and reason for the citation, and the eventual disposition of the citation(s):

Have you ever been convicted of a felony?

YES
NO

If yes, please describe the circumstances:

Any physical or mental conditions which may require an accommodation by the District to permit you to perform volunteer firefighting or emergency medical services?

YES
NO

If yes, please list a description of such condition(s), along with any medications currently prescribed which the District should be aware of in the event your application is selected (Please Note: The contents of this application are confidential and will not be disclosed to third parties other than authorized members of the Carbondale & Rural Fire Protection District):

Training

Have you ever had any prior training or experience in firefighting or emergency medical services?

YES
NO

State of Colorado firefighter level of certification:

FF1
FF2
Other

State of Colorado EMT certification level:

AFA
CPR
EMR
EMT-B
EMT-I
EMT-P

List any Additional training or skills i.e., rock climbing, river rafting:

Education

School / Major / Degree Received

Please list the name and location of the schools you have studied at along with your major and degree received.

Employment

Current Occupation

Current Employer

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

May we contact your employer for a reference?

YES
NO

Previous Fire Service Experience

1. Have you ever been a member of another fire department or fire protection district in the state of Colorado or elsewhere?

YES
NO

(If, no please skip to question #2)

Name of Fire/EMS Organization

Name of Chief

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Position in Organization

2. Briefly explain why you want to join the department:

References

Please list three (3) local references (references will be contacted):

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Whom to notify in case of emergency

Name

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Consent*

Correct & Voluntary Information

By my checking the box above, I affirm under the penalty of perjury that the information provided in this employment application (and accompanying resume, if any) is provided voluntarily, is true and complete. And I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification for my dismissal from employment, even if the omission or falsehood does not directly relate to my job or is not discovered for many years.

Consent*

Authorize Investigation

I authorize the investigation of all statements contained in this application. I also authorize contact with my present employer, past employers and any listed references

Consent*

Relevant Information

I authorize any persons, schools, current employers and organization names in this application form to provide CRFPD with relevant information and opinions that may be useful in making a hiring decision, and I release such persons and organizations from any legal liability for such information furnished.

Consent*

Membership

I understand that this application does not, by itself, create a contract of membership. I understand and agree that, if accepted my membership is for no definite period of time and may, be terminated at any time subject to the provision of the Volunteer Handbook as the same may be amended. I understand that no person is authorized to change any of the terms mentioned in this membership application form.

Files*

Drop files here or

Application for Membership

Training

Education

Employment

Previous Fire Service Experience

References

Whom to notify in case of emergency