GFR Membership Application

Applicant Information

Last Name *

First Name *

M.I.

Date of Birth

Street Address

Apt #

City

State

ZIP

Phone *

Email *

Membership Category

Active (Fire, EMS, or Driver) Support Member Junior

Background

Do you have a legal right to work in the United States? YES NO

Do you have a valid driver's license? YES NO

State

License Number

Have you ever been convicted of a crime? YES NO

If yes, please explain

Have you ever been convicted of Driving While Intoxicated or Under the Influence? YES NO

If yes, please explain

Have you ever been denied or terminated membership from a public safety agency? YES NO

If yes, please explain

Have you ever been dismissed or forced to resign from any position? YES NO

If yes, please explain

Education

High School

Address

From

To

Graduated?

YES NO

Degree

College

Address

From

To

Graduated?

YES NO

Degree

Other

Address

From

To

Graduated?

YES NO

Degree

Certifications

List relevant certifications (FFI, FFII, HAZMAT, EMT, NREMT, EVOC, CPR, ACLS, PALS, etc.)

Certification

Expiration

Employment History (most recent first)

Company

Phone

Address

Position

Supervisor

From

To

Reason for Leaving

Company

Phone

Address

Position

Supervisor

From

To

Reason for Leaving

Company

Phone

Address

Position

Supervisor

From

To

Reason for Leaving

Prior Public Safety Experience

Agency

Phone

Address

Position

Chief / Supervisor

From

To

Reason for Leaving

Agency

Phone

Address

Position

Chief / Supervisor

From

To

Reason for Leaving

References (do not include relatives or employers)

Reference 1

Full Name

Phone

Email

Relationship

Reference 2

Full Name

Phone

Email

Relationship

Reference 3

Full Name

Phone

Email

Relationship

Statement & Signature

I hereby certify that every statement I have made on this application and supporting documents is true and complete. I understand that any false information or omission may disqualify me from further consideration for membership and may result in my immediate discharge if discovered at a later date.

I authorize Gretna Fire & Rescue to investigate, without liability, all statements contained in this application and supporting materials. I also authorize references, employers, public safety agencies, and others, without liability, to make full response to any inquiries in connection with this application.

I understand that the use of illegal drugs is strictly prohibited and grounds for immediate termination. My signature authorizes drug screening, investigative reports, criminal history and driving record checks, reference checks, and physical examination if required.

Signature (type your full name) *

Date