If Present Address is less than 3 years, please list previous address.
Are you at least 18 years of age?
Are you a citizen of the U.S.?
EMERGENCY CONTACT INFORMATION EDUCATION
EMPLOYMENT RECORD Please list present and past employment from the most current to last. MILITARY SERVICE RECORD
REFERENCES Please list names of three persons not related to you, whom you have known for at least 3 years.
TERMS & CONDITIONS Please acknowledge the statements below by checking each box. “I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if I am successful in obtaining membership, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above, to give any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and other persons, agencies and departments, as follows, but not limited to: all law enforcement agencies for a record check, the Veterans Administration, all branches of the U.S. Armed Forces, all federal, state or local government agencies, state and federal tax bureaus, credit bureaus, schools and universities, and release all parties from all liability for any damage that may result from furnishing same to you. I understand and agree that, my membership is for no definite period and may, be terminated at any time without prior notice.” “I am also aware that if selected for membership, I will be asked to take a pre-placement examination performed by a licensed physician selected by the Fire District. The Fire District will pay for all cost for this examination. During the aforementioned examination, I am aware that drug testing will be done to determine the presence of any foreign substance in my body and if confirmed positive, I will not be eligible for membership with the Eureka Fire Protection District." “I acknowledge that the District will check my driver's license status. I am aware that I must maintain a valid driver's license while a member of the Eureka Fire Protection District." Submit Your application has been sent. One of our staff members will contact you soon. If you need immediate assistance, please call us at 636-938-5505.