Volunteer | Jefferson Monroe Fire Department

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JEFFERSON MONROE

Fire Department

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Our
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Position you are applying for*

Firefighter

Firefighter / EMS

EMS Only

Cadet (16-17 years old)

Auxiliary (Non-emergency response)

First name*

Last name*

Phone*

Email*

Birthday*

Month

Day

Year

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Employer

Employer Address

Employed Since

Position

Other Experience

Have you had a physical in the past year?

Yes

Last tetanus shot:

List any medical conditions which may affect job performance:

Allergies:

Hospital of choice

Education

High School Diploma

Vocational School

College Degree

Fire/Rescue Training

Firefighter 1

Firefighter 2

HazMat Operations

Instructor 1

Officer 1

ICS 100

ICS 200

NIMS 700

Other

Fire Service Experience

Department

Number of years

Emergency Medical Training

EMR (First Responder)

EMT

AEMT

Paramedic

Other

EMS Experience

Department

Number of years

Do you own a vehicle that you can drive to meetings, trainings, and calls?

Yes

Do you carry liability insurance on all vehicles that you may drive while participating in fire department activities?

Yes

Do you have any DUI or felony convictions?

Yes

Comments:

*Background checks will be conducted on all applicants for membership with the Jefferson-Monroe Fire Department.

I certify that all statements given on this form are true. I agree that I will obey all federal, state, and local laws, rules and regulations and follow the operational guidelines as prescribed by the Jefferson-Monroe Fire Department.

Physical Address

2559 120th St NW

Swisher, IA 52338

Mailing Address

PO Box 246

Swisher, IA 52338

Emergency

Dial 911

319-356-6800

Non-Emergency Dispatch

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Join Our Team!

Join
Our
Team!