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Volunteer Membership Application - Mansfield Fire Department

3. 

4. 

7. PERSONAL INFORMATION

9. First Name*

10. Last Name*

12. Email Address*

14. Address*

16. City*

17. State*

18. Zip Code*

20. Cell Phone Number*

21. Home Phone Number

23. Are you over the age of 18?*

    1. Yes
    2. No

25. Why do you wish to become a volunteer with the Town of Mansfield Fire Department?*

29. Do you hold a Valid Driver License?*

    1. Yes
    2. No

31. Which state?*

33. List any Driver License Endorsements here:

35. Do you own or have regular access to a vehicle for use in responding to calls?*

    1. Yes
    2. No

37. If convicted of any driving infractions in the past, please explain:*

41. Have you ever been convicted of any felonies or misdemeanors:*

    1. Yes
    2. No

43. If yes, explain. You are not required to disclose any arrest(s), criminal charge(s) or conviction(s) if the records have been erased under law. This information will not necessarily bar you from membership and will be kept confidential.

47. I will be required to take training courses that are mandatory by the Mansfield Fire Department and Federal and state laws

    1. I Understand

51. EMPLOYMENT HISTORY

53. Current Employer*

54. Occupation*

56. Supervisor Name*

57. Supervisor Phone Number*

59. Length of Employment*

    *If less than 2 years, provide name and address of previous employer

60. Employer Address*

64. Previous Employer

65. Previous Occupation

67. Previous Supervisor

68. Previous Supervisor Phone

70. Length of Previous Employment

71. Reason for Leaving

75. EDUCATION & TRAINING

77. High School Attended*

78. Year Graduated*

82. College Attended

83. Years Completed

85. Year Graduated College

86. Degree Achieved

90. Briefly describe the following: specialized training, apprenticeships, skills or extra-curricular activities, relevant coursework, foreign language skills, etc.

92. List any fire departments of which you have previously been a member or afiliated with.

94. List any certifications you received while previously a member at a fire department.

98. REFERENCES

100. Reference #1*

101. Email Address*

103. Address

105. City*

106. State

107. Zip Code

109. Phone Number*

113. Reference #2*

114. Email Address*

116. Address

118. City*

119. State

120. Zip Code

122. Phone Number*

126. I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for disqualification or dismissal. I authorize the use of any information in the application to verify my statement. If accepted for membership, I agree to abide by all the rules and regulations of the Mansfield Fire Department.

     Digital Signature

128. Date
     Date

     Date

Leave This Blank:


130. 1. Receive an email copy of this form.
131. Email address

     This field is not part of the form submission.

132. Submit Submit and Print

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