Application

[Printable Version]

Wadesville - Center Township Volunteer Fire Department

Name:  _________________________________    S.S.N.:  _____________________    DOB:  ____/____/____

Phone #:  ______-______-__________    Drivers LIC #:  __________________    Date of EXP:  ____/____/____

Married:  ________    Spouses Name:  __________________________    # of DEP:  _________

PHYSICAL CONDITIONS

Date of Last Physical:  ____/____/____    Height:  ________    Weight:  ___________

Have you received treatment from a physician or a practitioner in the last three (3) years?  Yes  or  No

If yes, please explain:  _________________________________________________________________________

__________________________________________________________________________________________

Are you willing to take a physical and agility test?  Yes  or  No

High school and date graduated:  ________________________________________

List any accidents or traffic violations in the last three (3) years:  _________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

NOTICE OF PROPOSED INVESTIGATIVE REPORT

As a part of our normal selection procedure we will request that an investigative report be made.

I consent to the release of any information concerning my capacity and and fitness by employers, physicians, and law enforcement agencies for selection of the above named department.

All of the statements made by me are true, complete, and correct to the best of my knowledge and belief and are made in good faith.

Name:________________________

Address:________________________

________________________

________________________

__________________________________

Signature of Applicant