Application

City of Moriarty Fire Department

Membership Application

Date of Application: //

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

Address:

City: State: Zip Code:

Phone Numbers: (Home)           (Work)

                                 (Cell)           (Pager)

Email Address:

Date of Birth: / /         SSN:

Drivers License Number:         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___________________________

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