*********************************

Fill out each space completely. If an area does not apply to you, write N/A in the space.

Please print legibly.

Last Name:__________________________ First:______________________ MI:___________________

SSN:_______________________________ Phone Number:_____________________________________

Address:____________________________ City:_________________ ST:_________ Zip:_____________

DOB:_______________________________Age:_____________ Marital Status:_____________________

E-Mail Address_________________________________________________________________________

Spouse’s Name Or Nearest Relative:_____________________________ Phone Number:______________

How Long Have You Lived At The Above Address?____________________________________________

Previous Address:_____________________ City:__________________ ST:____________ Zip:_________

Length Time At Previous Address:__________________________________________________________

Occupation:_________________________ Employer:__________________________________________

Supervisor:__________________________ Length Of Employment:______________________________

Address:____________________________ Phone:_____________________________________________

Hours and Days You Work:_______________________________________________________________

Previous Employer:___________________________________Phone Number:______________________

Length of Employment:___________ Reason For Leaving:______________________________________

Time Available For Response:_____________________________________________________________

Do You Have Any Physical Or Medical Impairments Which Would Prohibit You From Doing Your Job?

Yes____________ No__________________

Explain________________________________________________________________________________

How Much Time Have You Missed From Work In The Last Year Due To Injury Or Illness?____________

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______________________________________________________________________________________

Are You Interested In: Fire Fighting_________ EMS___________ Both_____________

Previous Experience As A Fire Fighter Or EMS Member. List All Departments Or Other Volunteer

Organizations You Have Been Affiliated With And The Dates You Were With Each Organization:

Department/Organization:___________________________ Dates:________________ Phone:__________

Reason For Leaving:_____________________________________________________________________

Department/Organization:___________________________ Dates:________________ Phone:__________

Reason For Leaving:_____________________________________________________________________

Emergency Medical Tech #:________________________ CPR Card Expiration Date: _____________

Fire Fighter Cert Date:_____________________________ Other:______________________________

Name Of High School Attended:______________________________________ Diploma Yes____ No____

List Any Other Formal Education You Have Received:__________________________________________

______________________________________________________________________________________

List Any Other Special Skills You Have:_____________________________________________________

______________________________________________________________________________________

Branch:______________________ Dates:__________ To _____________ Type Of Discharge:_________

Are you a member of any Reserve or National Guard Unit? Yes________ No__________

If Yes What Branch?_____________________________________________________________________

Three Character References (No Relations Please) (Fill Out All Required Lines)

____________________________________ _______________________ ______________

Name Relationship Phone #

____________________________________ _______________________ ______________

Name Relationship Phone #

____________________________________ _______________________ ______________

Name Relationship Phone #

Have you ever been arrested, indicted, or summoned into court as a defendant in a criminal proceeding; ever been convicted, fined, imprisoned, or placed on probation; ever been ordered to deposit bail or collateral for the violation of any law or ordinance (Excluding minor traffic violations, where a fine or forfeiture of $50.00 or less was imposed?) Yes______________ No__________________

If yes, please give details, including dates and places:___________________________________________

______________________________________________________________________________________

Have your driving privileges ever been suspended, revoked, or refused? Yes________ No_______

Driver’s License # ____________________________________________

State:___________________________ Expiration Date:______________________

Automobile Liability Insurance:

Name of insuring auto agent or company_____________________________________________________

Address_____________________________________ Phone____________________________________

I desire to become an active member of Alexandria Fire/EMS/Fire District #5. I hereby agree that if accepted, I will abide by the Policies, Procedures, and Guidelines of the District. I will attend the required amount of training and meetings and I will assist at department functions when possible. I further agree to obey all lawful orders from the Department Officers when on duty. I also understand that if accepted to membership, I shall be on probation as prescribed in Policy 103.04-103.05.

I understand that all Department issued equipment, including pager, charger, badge, turnout gear, uniforms, etc, issued to me, remains the property of the Department, and that I shall return all such property to the Department when I resign, become inactive, or my membership is terminated or suspended.

I hereby acknowledge that all questions have been answered truthfully and to the best of my knowledge. I understand that if any of the information in this application is found to be false, it can result in denial of my application or termination of my membership.

___________________________________________

Applicant’s Printed Name

____________________________________________________

Applicant’s Signed Name

____________________________________________________

Date Signed

4

I have applied for employment, or acting as a volunteer, with one of the following organizations: a paid or volunteer fire department (certified by the Commission on Fire Protection Personnel Standards and Education), an ambulance service (licensed by the Commonwealth of Kentucky), or a rescue squad (officially affiliated with a local disaster and emergency services organization with the Division of Disaster and Emergency Services). I know that the Alexandria Police Department will provide the employer with any record I may have for conviction of any felony crime. I know that I have a right to inspect my criminal history record and to request correction of any inaccurate information. If I do not exercise that right, I agree to hold harmless the Alexandria Police Department and Alexandria Police employees from any claim for damages arising from the dissemination of inaccurate information.

Applicant Information:

______________________________________________

Name (Last, First, Middle, Maiden)

Sex_________ Race______ Date of Birth____________ Soc Sec # _________________

Scars, Marks, Amputations, etc.______________________________________________

_________________________________________

Signature Date

_________________________________________________

Witness Date

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