City of Moriarty Fire Department

Membership Application

Date of Application: //

Name: (Last)(First)(M.I.)

Address:

City: State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:

Phone Numbers: (Home)           (Work)

                                 (Cell)           (Pager)

Email Address:

Date of Birth: Month 01 02 03 04 05 06 07 08 09 10 11 12 / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990         SSN:

Drivers License Number:     Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming     Exp. Date:

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

Have you ever been convicted of a DUI?     Yes     No

If yes to either question please explain:

Emergency Contacts: Name: Phone:

 Name: Phone:

Current Medical Licenses:

Current Fire Certifications:

Other Certifications/Trainings:

If you have any medical problems that could limit your abilities to perform in an EMS or Fire capacity, please list:

Have you ever been convicted of a felony?    Yes     No

If yes, please explain:

Release of Information:

I certify that the above information is true and correct to the best of my knowledge, and I authorize the City of Moriarty Fire Dept. to request from Moriarty Police Dept. a background check through the National Crime Information Center. I have further been informed that the information contained in this application will be kept confidential.

Signature:

Fire Dept. Use Only Date Application Accepted:                                               Badge Number:

Background Check on file                                     Drivers License Check on file

Fire Chief Signature___________________________

Webmaster: Capt. Steven Spann