Date:
INDIAN HARBOUR BEACH FIRE DEPARTMENT
1116 PINETREE DRIVE
INDIAN HARBOUR BEACH, FL 32937
Date: _______________
1. Name: ____________________________Spouse’s Name: ___________________
2. Address: ______________________ Phone: _____________ Cell: ____________
3. City: ________________________________ State: _______ Zip: _____________
4. Address (Previous 2 years): ____________________________________________
5. Date of birth: ________ Height:____ Weight:____ Color eyes:____ Color hair:_____
6. Single(__) Married(__) Divorced(__) Widowed(__) Social Security #:___-___-___
7. U.S. citizen : Yes(__) No(__) Drivers license: State/___ Number_______________
8. Occupation: _________________________________________________________
9. Name of employer: ___________________________________________________
10. Highest level of education completed:
High school(__) College -2 years(__) Bachelors Degree(__) Masters Degree(__) Doctorate(__) / List other Vocational training:_______________________________
___________________________________________________________________
10. Have you ever been arrested for other than a minor traffic violation? Yes(__) No(__)
If yes, explain:_______________________________________________________
11. Military service record: Branch of service: ___________ Highest rank:___________
Service number: ________________ Type of discharge: ______________________
12. Indicate any previous fire fighting experience or training: ______________________
___________________________________________________________________
___________________________________________________________________
13. C.P.R. Certified?: Yes(__) No(__) Indicate any first aid or other medical experience and certifications: ____________________________________________________ ___________________________________________________________________
14. List any other certifications, hobbies, or special skills that may benefit the fire department:_______________________________________________________________________________________________________________________________________________________________________________________________
15. Character reference: List two local residents of Florida that can ascertain that you are of good moral character.
Name Address Phone Occupation Yrs Known
______________________________________________________________________________________________________________________________________
16. Health record: Please answer the following medical history questions.
Do you or did you ever have…
Yes No
(___)(___) Prescription eyewear (___)(___) A rupture
(___)(___) Chronic cough (___)(___) Backaches or back injury
(___)(___) Tuberculosis (___)(___) Heart trouble or illness
(___)(___) Hearing trouble (___)(___) Asthma
(___)(___) Shortness of breath (___)(___) Fits or convulsions
(___)(___) High blood pressure (___)(___) Knee or hip injury
(___)(___) Stomach trouble (___)(___) Kidney or bladder trouble
(___)(___) Drugs or medication to take on a regular basis
If yes to any of the above, explain: _______________________________________ ______________________________________________________________________________________________________________________________________
17. Circle the general time(s) you would be available:
Morning Afternoon Evening Nights
I certify that all of the preceding statements and information given by me are complete and accurate. I hereby make application for membership, and if elected, agree to abide by all rules and regulations of the organization.
Signed: ________________________________________ Date: _______________
Proposed by: ________________________ Referred to:______________________
Fire Chief Recommendation: YES/NO
Interviewed by: _________________________________ Date: ________________
Comments: _________________________________________________________
Date accepted (Start date): ________________
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