DFA MEMBERSHIP

APPLICATION

NOTE: THIS INFORMATION IS BEING TRANSFERRED TO OUR MEMBERSHIP COMMITTEE BY E-MAIL. ALL APPLICATIONS, REAL OR FICTITIOUS, WILL REVEAL THE SENDER'S E-MAIL ADDRESS.

 

Application for:

Fire

Ambulance

Both

PERSONAL DATA

Name (Last, First, MI):

Street Address:


City:

State & Zip

Home Telephone:


Work Telephone:


Mobile Telephone:


E-Mail Address:

Date of Birth:

Social Security Number:

Occupation:


Present Employer:


Employer's Address:


Employer's City


Employer State & Zip:


Employer Phone:

DRIVER QUALIFICATIONS
 

State of Issuance:

 

Driver's License Number:

Class        Restrictions
   


Has your driver's license, permit, or privilege to operate a motor vehicle been suspended or revoked during the past 3 years?
 

Have you ever been arrested and/or convicted of any criminal or motor vehicle violations?
 


If yes to either question, please explain:

(This information will be used to investigate your driving record for the preceding three (3) years.)

EXPERIENCE

Have you ever been a member of a fire department, rescue squad or similar organization?
  

Name of Organization:


Address:


City


State & Zip:


Reason for Leaving:

List all prior fire/medical training and/or emergency schools attended:
(School, Location, Dates, Subjects Studied)

Have you ever applied to Dallas Fire & Ambulance Inc. before?
 

Reason for Leaving:
 

Do you have any physical limitations or fears (hearing, vision, speech, heights, etc.)?

Person to notify in an Emergency:


Address:


 City


State & Zip:


Emergency Contact Home Phone:

Emergency Contact Mobile Phone:

Emergency Contact Work Phone:

Additional Comments:

DECLARATION

The information on this application is accurate and subject to verification by Dallas Fire and Ambulance Inc. I understand furnishing of any misleading or incorrect information may result in termination of my membership. I hereby give permission to Dallas Fire & Ambulance Inc. or its duly authorized representative to contact any persons, companies, or educational institutions named in this application. I agree that I will not disclose or use in connection with my association with Dallas Fire and Ambulance Inc. any confidential  or proprietary information. I understand that my membership with Dallas Fire and Ambulance Inc. is at will and that such membership may be terminated at anytime by myself or Dallas Fire & Ambulance Inc. I further agree to abide by all By-Laws, Rules, and Regulations set forth governing membership in Dallas Fire & Ambulance Inc. I do certify that this application was completed by me and that all entries and information contained therein are true and complete to the best of my knowledge.

I have read and agree to the above:

Applications that do not agree to the above declaration will not be considered. Furthermore, a physical signature and copies of certifications may be required. Contact DFA for additional information.