Eddy County, NM

Department Membership Application Application for ___________________ Fire Department.

Name:__________________________________________Phone:___________________

Home Address:___________________________________________________________

Employer_____________________________Occupation:_________________________

Employer Address:________________________________________________________

Firefighting involves a stressful work environment where an individual is subject to extremes in temperature and life-threatening situations. The following abilities are expected of members of the volunteer fire department, please indicate if you are able to perform the duties listed:

Lift equipment weighing 50 pounds, and carry for a distance of 100 feet. __________
Walk, kneel, stand, and crawl while wearing bunker gear and SCBA. ________
Perform tasks in extreme temperatures, while wearing protective equipment._______
Listen to, understand, and carry out orders in emergency situations._______
Function within a wide range of unregulated environmental conditions.______

You are not required to disclose information about physical or mental limitations that you believe will not interfere with your capability to perform the duties of a firefighter, yet if you wish for the department to consider special arrangements to accommodate a physical or mental impairment, please identify that impairment and furnish suggestions for appropriate accommodations in the space provided.______________________________

_______________________________________________________________________

List any previous firefighting or related experience:______________________________

________________________________________________________________________________________________________________________________________________

List the names and phone numbers of three references:

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you currently a member of any other fire department? ___
Are you a resident of or are you employed within the fire district to which you are applying for membership? _____
Are you willing to respond to fires, attend department meetings, trainings, and drills?___

I, ______________________, do hereby swear that the above listed information is true and correct.

Signature:______________________________________Date:_____________________

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