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Membership Application

2. APPLICATION FOR MEMBERSHIP
   This application is for volunteer membership. Paid positions are posted on the City of Deer Park's job openings page.

   This application is for volunteer membership. Paid positions are posted on the City of Deer Park's job openings page.

4. Service Applying For*

   1. Volunteer Firefighter

   1. Volunteer EMS provider

   1. Volunteer Firefighter and EMS provider
6. First Name*

7. Last Name*

9. Address1*

11. City*

12. State*

13. Zip*

15. Date of Birth*
    Date of Birth

16. Place of Birth*

17. Sex*
    -- Select One --MaleFemale

18. Social Security Number*

20. Phone Number*

21. Email

22. Texas Drivers License Number*

23. Type of License*
    -- Select One --ABC

25. Marital Status*

    1. Single
    2. Married
    3. Divorced

26. Spouses Name*

    (N/A if not applicable)

27. Children*

    Number (N/A if not applicable)

31. EMPLOYMENT

33. Current Employer*

34. Phone Number*

35. Current Position*

36. Type of Schedule*

38. Address1*

39. City*

40. State*

41. Zip*

43. Previous Employer*

    (N/A if not applicable)

44. Address*

    (N/A if not applicable)

45. Phone Number*

    (N/A if not applicable)

47. Previous Employer*

    (N/A if not applicable)

48. Address*

    (N/A if not applicable)

49. Phone Number*

    (N/A if not applicable)

51. EDUCATION

53. High School*

54. Graduated*
    -- Select One --YesNo

55. Degree*
    -- Select One --DiplomaGEDDid Not Graduate

57. Address

58. City*

59. State*

61. College*

    (N/A if not applicable)

62. Graduated*
    -- Select One --YesNoN/A

63. Degree*
    -- Select One --N/ACertificateAssociate'sBachelor'sGraduate

64. Certificate/ Major*

    (N/A if not applicable)

66. Address

67. City*

    (N/A if not applicable)

68. State

    (N/A if not applicable)

70. Fire Certification(s)*

    (N/A if not applicable)

71. EMS Certification(s)*

    (N/A if not applicable)

73. CRIMINAL HISTORY

75. Have you ever been convicted of a crime, excluding traffic violations
    -- Select One --YesNo

77. If yes, please explain*

    (N/A if not applicable)

79. PHYSICAL HISTORY

81. Do you have any of the following?*

    1. Heart Disease
    2. Epilepsy
    3. Emphysema
    4. Asthma

    1. Diabetes
    2. Other
    3. N/A

82. Do you have any impairments with *

    1. Hearing
    2. Eyesight
    3. N/A

84. If you checked other, please explain*

    (N/A if not applicable)

86. The City of Deer Park Volunteer Fire Department will not accept physical examination papers from other physicians. The City of Deer Park Physician must examine all applicants.

88. REFERENCES

90. Name*

91. Address*

92. Phone Number*

94. Name*

95. Address*

96. Phone Number*

98. Name*

99. Address*

100. Phone Number*

102. By typing your name below you are certifying that all statements in this application are true to the best of your knowledge and understand that any falsification of records on this document will void any connection between yourself and the City of Deer Park Volunteer Fire Department. Additionally, by typing your name below you are consenting to a drug test and commiting to abide by the City of Deer Park's Policies on Acohol and Drug Abuse.

104. Name*

     (First and Last)

105. Date and Time of Application*
     Date and Time of Application

     Date and Time of Application

Leave This Blank:


107. 1. Receive an email copy of this form.
108. Email address

     This field is not part of the form submission.

109. Submit

* indicates a required field