Eva Volunteer Fire Department
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First Name:
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Last Name:
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Home Phone Number:
E-mail Address:
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Cell Number:
Wireless Provider
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AT&T @cingularme.com
Verizon @vtext.com
T Mobile @tmomail.net
Corr Wireless @sms.corrwireless.com
None of the above
Mailing Street Address:
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Physical Address:
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City:
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State:
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AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
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WI
WY
-Terr.-
AS
FM
GU
MI
PR
VI
Postal Code:
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How long have you lived at this address?
Drivers License Number:
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State Issued:
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AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
-Terr.-
AS
FM
GU
MI
PR
VI
Expiration Date:
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Current Employer:
*
Mailing Address of Employer:
City:
State
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
-Terr.-
AS
FM
GU
MI
PR
VI
Phone Number of Employer:
Email Address of Employer
Supervisors Name (Last, First)
Supervisors Phone Number:
How long have you worked here?
Highest Level of Education Completed:
*
9
10
11
High School Graduate
Some College
Associates Degree
Bachelors Degree
Masters Degree
Have you ever been a member of this departement?
*
Yes
No
If yes, what year(s)?
Are you, or have you been, a member with another fire depatment?
*
Yes
No
If yes, provide most recent department name, chiefs name, phone number or email address:
List any moving traffic violations in the past 5 years:
Have you ever been charged, or convicted, of DWI, DUI or class B or higher offense?
*
Yes
No
If yes, explain:
Check all that apply (must be current):
*
Fire Fighter I
Fire Fighter II
EMT - Basic
EMT - Paramedic
First Responder
CPR
None
Do you understand that the answers you have provided must be true and accurate, and that if you have provided false information, your application will be denied or you will be dismissed from the department?
*
Yes
No
Do you agree to submit a urine sample for drug testing at the expense of the Eva VFD?
*
Yes
No
Do we have your authorization to conduct a back ground investigation?
*
Yes
No
Comments / Questions:
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