Firefighter Application Form – Harpswell Neck Fire and Rescue

Legal Name

First

Middle

Last

Today's Date

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Physical Address (if different)

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email Address

Best Time(s) to Contact You

Place of Employment

Work department? recommended

Occupation

Work Phone

Emergency Contact

First

Last

Relation

Emergency Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Phone

Why do you want to volunteer with the fire department?

What role(s) are you interested in?

Please indicate any EMS or fire training you have completed, with date of completion.

Please indicate any other training that may be of value to the fire department, with date of completion.

If a member of the fire department recommended that you join, please provide their name.

Please provide three references

Reference 1

First

Last

Reference 1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 1 Phone

Reference 2

First

Last

Reference 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 2 Phone

Reference 3

First

Last

Reference 3 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 3 Phone

Entering my name below attests to the accuracy of the information provided and releases the fire department to obtain a driving record history, contact references and complete a criminal background check.

Name