Form Center

* indicates a required field

2. Personal Information
4. Full Name*
5. Date of Birth*
   Date of Birth
7. Driver's License Number*
8. Driver's License State*
10. Home Address*
11. City*
13. State*
14. ZIP*
16. Phone Number*

    (xxx) xxx-xxxx

17. Email Address*
19. Emergency Contact
21. Name*
22. Relationship*
24. Phone Number*

    (xxx) xxx-xxxx

25. Alternate Phone Number

    (xxx) xxx-xxxx

27. Employment Info
29. Current Employer*
30. Occupation/Title*
32. Supervisor's Name*
33. Work Phone*

    (xxx) xxx-xxxx

35. Availability
37. Are you available on weekdays?*

    1. Yes
    2. No
38. Are you available weekends?*

    1. Yes
    2. No
39. Are you willing to attend regular training sessions?*

    1. Yes
    2. No
41. Physical and Medical Information
43. Do you have any physical limitations that may affect your ability to serve as a firefighter?*

    1. Yes
    2. No
44. If yes, please explain*
46. Education and Training
48. Highest Level of Education Completed*

    1. High School
    2. Associate's Degree
    3. Bachelor's Degree
    4. Other
49. If other, please explain*
51. Firefighting or Emergency Response Training/Certification*

    1. None
    2. CPR/First Aid
    3. EMT
    4. Firefighter I / II
    5. Other
52. If other, please explain*
54. Background Information
56. Have you ever been convicted of a felony?*

    1. Yes
    2. No
57. If yes, please explain*
59. Have you ever been terminated from a job or volunteer position?*

    1. Yes
    2. No
60. If yes, please explain*
62. Refrences (Non-Family)
64. 1. Name*
65. 1. Phone Number*

    (xxx) xxx-xxxx

66. 1. Relationship*
68. 2. Name*
69. 2. Phone Number*

    (xxx) xxx-xxxx

70. 2. Relationship*
72. Acknowledgement and Signature
74. Date*
    Date
76. Signature*

    I hereby certify that the information I’ve provided is true and complete. I authorize the City of Avenal to investigate all statements made in this application and to contact references and past employers. I understand that I may be required to undergo a background check, medical evaluation, and drug screening. 

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77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

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