APPLICATION FOR MEMBERSHIP: First Name (required) Last Name (required) Full Address Street Address 1 Street Address 2 City State Zip Mailing Address Street Address 1 Street Address 2 City State Zip Home Number Cell Phone Number Work Phone Number Email (required) Training Have you ever had any prior training or experience in firefighting or emergency medical services? Yes No If firefighter, current level: FF1 FF2 Other: If medically trained, current level: AFA CPR EMT-B EMT-I EMT-P Other: Current State in which you are certified and expiration date: Additional training: MAST IV ACT ACLS Extrication Other training: 1. Have you ever been a member of another fire department or fire protection district in the state of Colorado or elsewhere? Yes No 2. Have you previously served as a volunteer or paid staff member with this Authority? Yes No 3. 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 1 Name Address Phone Reference 2 Name Address Phone Reference 3 Name Address Phone Your Signature (required) Confirm e-Signature Review Electronic Records and Signatures Policy (required)Read our Electronic Record and Signature Disclosure I agree to use electronic records and signatures Date (mm/dd/yyyy) (required) File Upload Are you 21 or over? Yes No There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
