Cedar Mountain Fire Protection District
(435)682-3225 Bus. (435) 682-3206 Fax
Email-cmfpd@color-country.net www.cmfpd.com
PLEASE PRINT
CLEARLY
Name:(First)__________________(Middle)________________(Last)_____________________
Home Address:
Street______________________________________________________________
City______________________
State____________________
Zip_____________________
Telephone:(Home)_____________________________(Work):
___________________________
E-mail___________________________________
Pager/Cell ______________________________
Have you lived in
What other states have you lived in
over the past seven years? _______________________
Previous Address:
Street___________________________________________________________
City:
Do you have a valid Utah State
Drivers License? (Attach photo copy)
Yes: ____ No: ____ License No:
__________________ Expires: __________________
Date of Birth
_______________________ SSN: _____________________ (attach photo copy)
Are you over 18 years of age? _________ If not,
your age ______________________ and
Parent/Guardian Signature (required) _______________________
Date ________________
Height ___________ Weight ______________
Circle your highest education level: High School Diploma GED Associates
Bachelor Degree Graduate Degree Major Field of study:
__________________
Person
to contact in case of Emergency: ___________________________________________
Name Phone
Give Two Personal References:
1.
Name:_______________________ Address: ________________________________
City: ________________________ Phone:
__________________________________
Occupation: ________________________ Years Known:
___________________
2.
Name:_______________________ Address: ________________________________
City: ________________________ Phone:
__________________________________
Occupation: ________________________ Years Known:
___________________
Do
you have any physical limitations, restrictions or disabilities that may affect
your ability to perform duties as needed at an Emergency Scene?
Yes
______ No _____If yes explain: _________________________________________________
____________________________________________________________________________________
Do
you have any objection submitting to a physical examination if requested by the
Cedar Mountain Fire Department?
Yes
_____ No ____If yes, explain:
___________________________________________________
___________________________________________________________________________________
Would
you have any objection submitting to an Alcohol or Drug screening if requested
by the Cedar Mountain Fire Department?
Yes
____ No ___If yes, explain:
_____________________________________________________
____________________________________________________________________________________
Have
you been convicted of any criminal felony; or of a misdemeanor involving
domestic violence; or of any motor vehicle moving violation in the last seven
years:?
Yes: _____ No: _____ If
yes, explain _________________________________________________
Would
you have any objection to the Cedar Mountain Fire Department conducting a
criminal background check?
Yes____
No____ If yes, explain: _____________________________________________________
____________________________________________________________________________________
Would
you have any objection to submitting or Cedar Mountain Fire Department
obtaining a certified copy of you driving record?
Yes ____ No ____If yes, explain:
____________________________________________________
___________________________________________________________________________________
Are you now or have you ever been in the Fire
Service? Yes ______ No ______
Where:__________________________________
Dates: __________________________________
What was your function?
__________________________________________________________
Supervisor:
____________________________ Phone: ____________________________
Medical Training:
Do you have a current card as an Emergency Medical Technician, First
Responder, or Advanced First Aid? Yes___
No ___ Card #:____________________
While performing your duties with this Fire
Department, you may come in contact with persons suffering from communicable
diseases. Have you ever been inoculated
against Hepatitis, Measles, Mumps, and Rubella?
Yes _____ No _____
If not, are you willing to receive any necessary
inoculations? Yes _____ No _____
Upon acceptance in the Cedar Mountain Fire
Department, you are expected to participate in extra curricular activities
listed but not limited to: Parades,
Training (mandatory), work details, and other duties as requested by the Fire
Department.
Do you agree to the above activities: Yes
__________ No __________
If no, explain_______________________________________________________________________
I further
understand that upon acceptance into the Cedar Mountain Fire Protection
District, I’m on a one year probation period.
I must meet all the above requirements.
Failure to do so will result in Dismissal from the Fire Department. If it is discovered at any time that you made
a willfully false statement, it will be considered just cause for dismissal
from the Fire Department. I also
understand that all entry pass, keys, tags, plates, electronics, pagers,
radios, gear, badges, uniforms and other equipment is property solely of the
Cedar Mountain Fire Protection District.
An I will be responsible for all the above at
replacement cost.
_________________________________________ ____/____/____
Signature
of Applicant Date
_________________________________________ ____/____/____
Signature
of Chief Date