Merton Fire Department

Application for Membership
Please complete the following form and submit for review.
CLICK HERE for a Information Release Form. This form will also need to be completed,
signed and delivered to Merton Fire Department prior to membership consideration.
Thank you for your interest.

Date of Application:

Name:

Social Security #:

Address:

City:

Zip/Postal Code:

State/Prov.:

Telephone (Home):

Email:

Check the position(s) you are interested in (you can choose more than one):
Firefighter EMT

Length of Residency at the above address at time of application Years Months

Marital Status :

Name of Spouse:

Driver's License #:

Has your Driver's License ever been revoked:
If yes, please explain:

Date of Birth:

Age:

Have you ever been treated for or suffered from any of the following (Check all that apply):

Heart Disease

Diabetes

Asthma

Respiratory Disorders

Back Injury

COPD

Confined by injury or illness for more than 10 days
If Yes, please explain:

Present Employer Name:

Address:

Hours of Work:

Employment History (last job first):

Company Name:		Address:
Job Title:		Name of Supervisor:
Telephone:
Company Name:		Address:
Job Title:		Name of Supervisor:
Telephone:
Company Name:		Address:
Job Title:		Name of Supervisor:
Telephone:
References:
Name:		Address:
Telephone:		Relationship:
Name:		Address:
Telephone:		Relationship:
Name:		Address:
Telephone:		Relationship:
Have you ever been convicted of: Felony Misdemeanor If Yes, please explain:
Have you ever been in the armed forces? Yes No If Yes, Which Branch:
Dates of Service:
Have you been a Fire Fighter and/or EMT Prior to Applying? Yes No

If Yes, Which Department?

Length of Service:

Please list any Titles Held and Special Training:

Would you be interested in any specialized training (EMT-I, Hazardous-Materials, Etc.) if you become a member of the Merton Fire Department? Yes No

If Yes, Please Explain:

Do you have or foresee any problems with heights, being confined to small places for lengthy periods of time, or possibly with putting on self-contained breathing apparatus? Yes No
If Yes, Please Explain:

What would your availability time to be on call if you become a member of our service?

Reason for Applying, Please Explain:

Comments or Questions about the Merton Fire Department: