Clark County Fire District 6

Name: Last	First	Middle

Address: Street	City	State	Zip

Phone#	SS#	Birth Date

Height	Weight	Color Hair	Color Eyes	Blood Type

Present Occupation	Position	Employer

Work Address: Street	City	State	Zip

Military Service: Branch	Dates	Type of Discharge

Formal Education

Fire Service Experience: Department	Dates

Positions Held

Describe any physical disabilities you have, including vision, if any, with or without glasses, and deficiencies in color vision and hearing.

Driver's License Number	Expiration Date

List Traffic Citations in last 5 Years

Have you ever been arrested for anything other than traffic violations? Yes No

Please list your employment history for the last five (5) years.

In Case of Accident or Death notify:

Personal References (Not Relatives)
Reference #1 Name: Last	First	Phone

Address: Street	City	State	Zip

Reference #2 Name: Last	First	Phone

Address: Street	City	State	Zip

Reference #3 Name: Last	First	Phone

Address: Street	City	State	Zip

Does your employer know of this application? Yes No

Is he/she in favor of it? Yes No

I hereby certify that all of the statements made in this application are true and complete as far as I can determine, and I understand that any misstatements of material acts may subject me to disqualification or dismissal.