Clark County Fire District 6

Volunteer Firefighter Application

Name

Last		First	Middle
Address		City	State	Zip
Phone		Email	Date
Eye Color		Hair Color	Blood Type
Driver License #		State
List Traffic Citations (5yrs)
Ever Arrested?	If yes, explain

Work

Occupation	Position	Employer
Address	City	State	Zip
Employment History

Military

	Check if you have Military Service	Branch		From Date		To Date
Discharge Type

Education

Level

Last School or College Attended

Fire Service Experience

Department		From Date		To Date
Supervisor		Position(s) Held

References (Not Relatives)

Reference #1 Name (first,last)	Phone
Address	City	State	Zip
Reference #2 Name (first,last)	Phone
Address	City	State	Zip
Reference #3 Name (first,last)	Phone
Address	City	State	Zip

I hereby certify that all statements made in this application are true and complete to the best of my knowledge. I understand any false information submitted is grounds for disqualification or dismissal.