APPLICATION - Holts Summit Fire Protection District

Name(Required)

First Middle Last

Address(Required)

Street Address City State ZIP Code

E-mail(Required)

Positions Interested In:(Required)

Volunteer Firefighter

Support Staff

EMS Only

Explorer Program

Part-Time Paid Fire Fighter

Upload Resume:(Required)

Max. file size: 50 MB.

Date of Birth(Required)

Drivers License #(Required)

Home/Cell Phone(Required)

Work Phone

Occupation

Employer

List place(s) of residence for last 5 years. Most current first:(Required)

Address

City

State

Zip

List place(s) of Employment including supervisors for the past 5 years. Most current first:

Employer

City

Dates

Supervisor

List all schools attended, including trade schools and/or Military experience.

School

City

Years

Degree

Please describe why you are interested in becoming a member of the Holts Summit Fire Protection District:(Required)

Have you ever been convicted of a felony or any other notable crime?(Required)

No

Yes

If yes, list dates and offenses:(Required)

Have you ever been convicted of a moving traffic violation?(Required)

No

Yes

If yes, list dates and offenses:(Required)

Have you ever had your driver’s license revoked or suspended in any state?(Required)

No

Yes

If yes, list dates, offenses and dates of reinstatement:(Required)

How do you describe your overall health?(Required)

Do you have a history of any heart of respiratory problems?(Required)

List 3 local references that are not relatives

Name(Required)

Phone(Required)

Name(Required)

Phone(Required)

Name(Required)

Phone(Required)

List all previous affiliations with Firefighting, Emergency Medical, Rescue or Law Enforcement agencies:

Organization

City

Supervisor

Dates

Rank

Do you have any Firefighter training?(Required)

Yes

No

If yes, list agencies and dates providing training:

Location

Dates

Course Titles

Do you have any other specialized training? (i.e. diver, small engine repair, welding, CPR, etc.)(Required)

Yes

No

If yes, list specialized training:(Required)

How will membership in this organization effect your family and employer?

What hours would you most likely be able to respond to an alarm?

Would you be able to respond from work?

Yes

No

Other

Do you have automobile insurance?(Required)

Yes

No

If yes, list company and policy number.(Required)

Company

Policy #

Do you have health insurance?(Required)

Yes

No

If yes, list company and policy number.(Required)

Company

Policy #

Do you have life insurance?(Required)

Yes

No

If yes, list company and policy number.(Required)

Company

Policy #

Are you currently taking any medication that could impair your ability to work in hazardous situations?(Required)

No

Yes

If yes, list medication:(Required)

I certify that all information that is disclosed in this application is factual. I also authorize the Holts Summit Fire Protection District to contact any or all persons listed in this application to ascertain my suitability as it pertains to the Districts’ needs. I acknowledge the fact that should I be accepted as a member of this organization, that I would be in probationary status for a period of at least 6 months and that this is a volunteer organization.

Signature(Required)

Date(Required)

This organization does not restrict applicants based upon sex, race, religious preferences or disabilities. We encourage all interested residents of our district, over the age of 18 to apply for any openings.

Membership Application

Dedicated to serving our community with integrity, courage and passion

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