APPLICATION FOR MEMBERSHIP:First Name (required)Last Name (required)Full AddressStreet Address 1Street Address 2CityStateZipMailing AddressStreet Address 1Street Address 2CityStateZipHome NumberCell Phone NumberWork Phone NumberEmail (required)TrainingHave you ever had any prior training or experience in firefighting or emergency medical services?YesNoIf firefighter, current level:FF1FF2Other:If medically trained, current level:AFACPREMT-BEMT-IEMT-POther:Current State in which you are certified and expiration date:Additional training:MASTIVACTACLSExtricationOther training:1. Have you ever been a member of another fire department or fire protection district in the state of Colorado or elsewhere?YesNo2. Have you previously served as a volunteer or paid staff member with this Authority?YesNo3. When did you join?4. When did you resign?If you are accepted as a member, it will be your responsibility to supply our department with documentation from your previous fire chief(s) of your dates of service, as well as your training hours and any additional non-confidential information pertaining to your qualifications and credentials.5. List any foreign languages you speak:6. Briefly explain why you want to join the department:Please list three (3) local references:Reference 1NameAddressPhoneReference 2NameAddressPhoneReference 3NameAddressPhoneYour Signature (required)Confirm e-SignatureReview Electronic Records and Signatures Policy (required)Read our Electronic Record and Signature Disclosure I agree to use electronic records and signaturesDate (mm/dd/yyyy) (required)File UploadAre you 21 or over?YesNoThere was a problem saving your submission. Please try again later.Please wait while your submission is being saved...Submitting...SubmitThank you, your submission has been received.
