Date of Birth (mm/dd/yyyy) ______________ social security # ________________

do you have a high school diploma? (y/n) _____ school ____________________

have you attended college? (y/n) _____

details _____________________________________________________________________

Have you ever been convicted of a crime? (y/n) _____

Who referred you to this department? ____________________________________

I, the undersigned, in consideration of appointment as a call firefighter, agree to abide by the rules and regulations of the hopkins hill fire department. i understand that my appointment as a call firefighter is subject to the approval of the fire chief of the DEPARTMENT. Upon withdrawing or being expelled from said district, I will return all district property to the chief of the department.

Applicants Signature_______________________________________________________

Parents or Guardian Signature (IF A MINOR)____________________________________________

FOR OFFICIAL USE ONLY

APPLICATION REVIEWED BY: _________________________ DATE: ___________ ID ASSIGNED: _____________

REMARKS: ______________________________________________________________________________________