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2. First Name*
3. Last Name*
5. Address
7. City
8. State
9. Zip
11. E-mail address*
12. T-Shirt size
14. Home phone
15. Work phone
17. Cell phone*
18. Date of birth
20. Drivers License No.
21. State Issued
23. Employer
25. Work Address
27. CIty
28. Zip code

30. ---

    
    Please list the requested information for three Personal References.
32. 1. Full Name*
34. Home Address
36. City
37. State
38. Zip
40. Phone*
41. Other Phone
43. 2. Full Name*
45. Home Address
47. City
48. State
49. Zip
51. Phone*
52. Other Phone
54. 3. Full Name*
56. Home Address
58. City
59. State
60. Zip
62. Phone*
63. Other Phone
65. What is your purpose for attending the Citizens Fire Academy?
67. If you have ever been convicted of a crime, please explain in detail.

69. ---
71. I, (Your name)*
73. hereby acknowledge that I have completed the above information completely and accurately to the best of my knowledge. I give my permission to the Mesquite Fire Department to inquire about my qualifications and/or character. I understand that the information requested is for the purpose of a background/reference check, and this check may be made by phone or in writing and may include present and past employers, motor vehicle and police records. Permission is hereby granted to conduct a background investigation based on the information given in this application.
    
    I also authorized my employer and any persons who may have information concerning me and my background to furnish such information to the extent allowed by law and for the intended purpose of my application to perform as a volunteer for the City of Mesquite Fire Department and hereby consent to the release of such information.
    
    I certify that all information contained on this application is true and complete to the best of my knowledge and belief. I understand that any misrepresentation, omissions or falsifications will result in my removal from volunteer activities with the Mesquite Fire Department.
    
    As a volunteer, I understand that the City of Mesquite does not provide volunteers with employee benefits, accident insurance, death benefits, compensation for lost time due to injury, nor does the City carry general liability insurance covering volunteers.
75. Signature*
76. Date
    Date
Leave This Blank:


78. 1. Receive an email copy of this form.
79. Email address

    This field is not part of the form submission.

80. Submit

* indicates a required field