2. 
4. DAPHNE FIRE DEPARTMENT: VOLUNTEER FIREFIGHTER APPLICATION
6. APPLICANT NAME*
7. DATE OF APPLICATION*
   DATE OF APPLICATION
9. HOW DID YOU HEAR ABOUT US?
11. APPLICANT STREET ADDRESS*
13. CITY*
14. STATE*
15. ZIP*
17. CONTACT NUMBER: CELL*
18. CONTACT NUMBER: HOME
19. CONTACT NUMBER: WORK
21. EMAIL ADDRESS*
22. MARITAL STATUS

    1. Married
    2. Single
24. DATE OF BIRTH*
    DATE OF BIRTH
25. AL DRIVERS LICENSE NUMBER*
27. EMERGENCY CONTACT*
28. RELATIONSHIP
30. EMERGENCY CONTACT NUMBER: CELL*
31. EMERGENCY CONTACT NUMBER: OTHER
35. Are you 21 years of age or older?

    1. Yes
    2. No

    (Note: you may be accepted for membership at age 18, but you will not be allowed to operate a City-owned vehicle.)

    ** If under the age of 21, please complete the Agreement for Members Under the Age of 21 section below.

37. AGREEMENT FOR MEMBERS UNDER THE AGE OF 21

    The City’s liability insurance carrier requires all insured drivers of City vehicles be at least 21 years of age and have an acceptable driving record. Individuals 18-20 years of age are allowed to serve as members on Daphne Fire Department. However, these individuals will not be allowed to drive ANY City vehicle of any kind while volunteering. Once reaching the age of 21, their name will be submitted to the insurance carrier for insurance coverage approval. The individual cannot operate any vehicle until the DFD Fire Chief receives the approval from Human Resources.     

    I understand that, as a volunteer under the age of 21, I may not drive any City vehicle. It is my responsibility to adhere to this requirement. I understand that a violation of this agreement will automatically result in my dismissal from membership with the Daphne Fire Department. I will notify the appropriate individuals within the DFD and Human Resources when I reach the age of 21 for insurance coverage submittal. 

39. APPLICANT DIGITAL SIGNATURE

    (If under the age of 21)

40. APPLICATION DATE
    APPLICATION DATE
44. Have you ever filed an application with the Daphne Fire Department?

    1. Yes
    2. No
45. If "Yes," please specify date(s):
47. Have you ever been a member of the Daphne Fire Department?

    1. Yes
    2. No
48. If "Yes," specify date(s) & reason for non-status:
50. Have you ever belonged to a fire department?

    1. Yes
    2. No
51. If "Yes," specify date(s) & location:
53. Have you ever served in the Armed Forces?

    1. Yes
    2. No
54. If "Yes," what was your highest rank?
56. Branch?
57. Type of Discharge?
59. Do you understand that you will be called upon at all hours, if needed, if you are accepted into membership?

    1. Yes
    2. No
61. Have you ever had your Driver's License revoked?

    1. Yes
    2. No
62. If "Yes," please explain:
64. In the past five (5) years, have you had any traffic violations for the following?

    1. Speeding
    2. DUI

    1. Reckless Driving
    2. Running Stop Sign
66. If "Yes" to any of above, please note number of times & state:
68. Have you ever been convicted of a crime other than minor traffic violations?

    1. Yes
    2. No
69. If "Yes," please explain:
71. Have you ever lived outside of the State of Alabama?

    1. Yes
    2. No
72. If "Yes," please list state & length of time:
76. EDUCATION
78. HIGH SCHOOL NAME
79. HIGH SCHOOL LOCATION
81. Highest year completed:

    1. 9th
    2. 10th

    1. 11th
    2. 12th
83. Diploma or GED received?
84. Specific course of study?
86. Describe any specialized training, skills and/or extra-curricular activities:
88. Describe any honors and/or awards received:
92. TRADE/VOCATIONAL OR COLLEGE/UNIVERSITY NAME
93. SCHOOL LOCATION
95. Highest year completed:

    1. 1
    2. 2

    1. 3
    2. 4
97. Diploma or Degree received?
98. Specific course of study?
100. Describe any specialized training, skills and/or extra-curricular activities:
102. Describe any honors and/or awards received:
106. COLLGE/UNIVERSITY NAME
107. COLLEGE/UNIVERSITY LOCATION
109. Highest year completed?

     1. 1
     2. 2

     1. 3
     2. 4
111. Diploma or Degree received?
112. Specific course of study?
114. Describe any specialized training, skills and/or extra-curricular activities:
116. Describe any honors and/or awards received:
120. Have you ever had emergency vehicle driver's training?

     1. Yes
     2. No
121. If "Yes," specify date & location:
123. Have you ever had defensive driver's training?

     1. Yes
     2. No
124. If "Yes," specify date & location:
126. Have you ever had courses in any of the following training?

     1. Fire fighting
     2. CPR

     1. First Aid/EMT/Paramedic
     2. Hazardous Materials
128. If checked, to what extent?
130. Summarize any other special related skill(s) and/or qualifications you may have:
132. Upload any copies of Certifications, EMS Licenses, CPR, NIMS certificates, etc.:
136. APPLICANT STATEMENT

     I certify those answers given by me to all questions on this application are to the best of my knowledge and belief, true and correct, without mental reservations of any kind whatsoever.  I further affirm that I have not knowingly withheld any fact or circumstances that would detrimentally affect this application.  I understand any false statement or omission of material facts shall be considered sufficient cause for dismissal. I authorize investigation of all statements contained in this application for membership as may be necessary in arriving at a membership decision. This application for membership shall be considered active for a period of time not to exceed 45 days.  If I wish to be considered for membership beyond this time period, I should inquire as to whether or not applications are being accepted at that time. I understand if I become a member of Daphne Fire Department, such membership does not constitute membership for a fixed or guaranteed period of time and that such membership, including any and all terms and conditions relating thereto whether presently in existence or adopted at some later date, is and are terminable in accordance with the policy, procedure and practice of Daphne Fire Department and the City of Daphne. I elect to be a member of a drug-free organization and agree to all provisions in the Drug and Alcohol Policy set forth by the City of Daphne. I understand I am required to abide by all rules and regulations by Daphne Fire Department and the City of Daphne.

138. APPLICANT DIGITAL SIGNATURE*
139. DATE OF DIGITAL SIGNATURE*
     DATE OF DIGITAL SIGNATURE
Leave This Blank:


145. 1. Receive an email copy of this form.
146. Email address

     This field is not part of the form submission.

147. Submit

* indicates a required field