Duquesne Annex Application

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Full Name (First and Last Name) *

Address *

Phone Number *

Email Address

Date of Birth *

YYYY

Occupation *

Do you have any physical limitation, which would restrict your ability to perform firefighter duties ? *

Yes

If yes, please explain:

Driving Privileges: Are your driving privileges revoked or have they ever been revoked *

Yes

If Yes, please explain

List current membership in other Fire Departments if any *

Previous Experience *

Have you ever been arrested or do you have a criminal record ? *

Yes

If Yes, Please explain

List any special licenses or certifications you currently hold:

List current fire service & emergency medical training (or submit resume)

Read this application and your answers carefully before signing below

I certify that the statements made by me on this membership application are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that if I have knowingly made a misstatement of these fact, I am subject to rejection and/or removal as a member of the Fire Company and Fire Department. I further understand that if I knowingly made any false statement regarding my criminal history, I will be subject to rejection and/or removal as a member of the Fire Company and Fire Department.

I have agreed to the above certification - Type full name below if you agree as your digital signature *

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