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2. 
3. Colchester Fire Department Volunteer Application
5. 1. PERSONAL INFORMATION
7. Today's Date*
   Today's Date
9. Last Name*
10. First Name*
11. Middle Initial
13. Street Address*
14. City
15. State*
17. Zip Code*
18. Mailing Address
    If different from street address.
20. Cell Phone Number*
21. Home Phone
22. Email Address*
24. Do you have a valid driver's license?*

    1. Yes
    2. No
25. Are you applying for:*

    1. Volunteer Membership (18+)
27. Education:*
    -- Select One --High School GraduateSome College /College StudentCollege Graduate
28. Years Completed*
29. Name of current or last school attended:*
30. City and State
32. Are you an active or past military member?*

    1. Yes
    2. No
33. Branch
34. Dates From:
35. To:
37. Military training / experience relevant to membership.
39. 2. EMPLOYMENT HISTORY
41. Current Occupation*
    If not employed enter n/a.
42. Current employer
43. Dates: From
44. To:
46. Supervisor's Name
47. Supervisor's Phone
48. Supervisor's Email
50. Permission to contact employer?

    1. Yes
    2. No
51. Job Title and Responsibilities
53. Past Employer
    If none enter n/a.
54. Dates: From
55. To:
57. Supervisor's Name
58. Supervisor's Phone
59. Supervisor's Email
61. Permission to contact past employer?

    1. Yes
    2. No
62. Job Title and Responsibilities
64. Past Employer
    If none enter n/a.
65. Dates: From
66. To:
68. Supervisor's Name
69. Supervisor's Phone
70. Supervisor's Email
72. Permission to contact past employer?

    1. Yes
    2. No
73. Job Title and Responsibilities
75. 3. Fire Service & Emergency Medical Training
77. List all Certifications (Course Name(s), Location(s), Month(s)/Year(s))
79. Are you currently enrolled in any Fire or EMT licensure class?*

    1. Yes
    2. No
80. Please list all organizations you have been affiliated with.
82. Please select your availability for the given days and times. *

    Check all that apply

    1. Weekdays
    2. Weeknights

    1. Weekends
84. Describe your interest in becoming a volunteer with the Colchester Fire Department.*
86. 4. Medical Information
88. Requirements:

    1. Yes
    2. No

    The law requires firefighters to be physically capable of performing emergency duties. Do you have any physical limitations which would restrict your ability to perform these duties?
90. If yes, please explain
92. 5. REFERENCES
94. Please provide three references (not related to you) including name, occupation, and contact information (phone or email).
96. Reference 1:*
97. Occupation
98. Phone
99. Email
101. Reference 2*
102. Occupation
103. Phone
104. Email
106. Reference 3*
107. Occupation
108. Phone
109. Email
111. Electronic Signature Agreement
113. By electronically signing below you agree and acknowledge that:
     1. You authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature
     2. You may still be required to provide a traditional signature at a later date.
     3. The information provided is true and accurate to the best of your knowledge.
     4. You authorized the verfication of any or all of the information and any inquiries permissible by law to determine suitability for membership. Any intentional misrepresentation may lead to denial of membership.
115. Certificate of Truthfulness*

     1. I certify that this is accurate

     I certify that the information I have provided on this application is true and accurate to the best of my knowledge. I understand that omissions or misrepresentations may be cause for rejection and/or removal as a member of the Colchester Fire Department.
117. Electronic Signature*
119. If applicable, please attach current EMS certification cards.
     One upload per field.
120. Upload certification.
     One upload per field.
121. Upload Certification
     One upload per field.
123. Optional: Attach Resume
     One upload per field.
Leave This Blank:


125. 1. Receive an email copy of this form.
126. Email address

     This field is not part of the form submission.

127. Submit Submit and Print

* indicates a required field