Volunteer Form

Application for Membership

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

**Please include the following with your completed application: Any current certifications you have, a copy of your Driver’s License and a copy of your DMV record.**

Volunteer Form

Application for Membership

Training

Education

Employment

Previous Fire Service Experience

References

Whom to notify in case of emergency