<= /span> WELLINGTON FIRE &= nbsp; &nbs= p; &= nbsp;

PROTECTION DISTRICT = protecting lives and property

= 8130 3RD ST., P.O. BOX 10

= WELLINGTON, CO 80549

= &nb= sp; (970) 568-3232

Volunteer Position Applying For: _____________________________________Date:_______________

Last Name: __________________________First Name: ____________________________Middle: ________________

Address: ___________________________________________E-Mail: __________________________

City: _____________________________State: _________________________Zip:________________

Phone #’s: (H) ______________________ (W) :____________= ______________( C):________________

Are you 18 years of age or older? Yes ____ No _____

Are you a U.S. Citizen or an alien authorized to work in the United States? Yes___ No___

You are respo= nsible for providing a copy of your current drivers license check. The Fire District will be

conducting a = Criminal Background check and Drug Screen on all applicants. Your Signature on the District̵= 7;s Background Authorization Form is required.

Have you had Fire and/or Rescue service experience? Yes___ No___

Name of Organization: _______________________________________________________________

Address of Organization: _____________________________________________________________

Phone #: _________________________ Contact Person: ___________________________________

Dates Served: __________________________ At the time of your departure, what were your general responsibilities?

______________________________= ___________________________________________________________________

What Skills, qualifications an= d/or certifications do you posses? ___________________________________________________________________________= ________________________

Education: &= nbsp; School &= nbsp; &nbs= p; &= nbsp; Course &= nbsp; &nbs= p; Did you graduate? = &nb= sp; Year

High School: _______________________ ________________________ ___________________________ _____________

College: ___________________________ _____= __________________ ___________________________ _____________

Other: _____________________________ ______________________ ___________________________ _______________

Experience: (List the l= ast two (2) companies you worked for)

Name of Company: ___________________________________________________________________________= __________

Address of Company: __________= _________________________________________________________________________

Phone #:______________________= ____ Supervisor: _________________________________________

Dates Employed: From ___________To____________Reason for Leaving________________________________= _________________________________________________________

Name of Company: ___________________________________________________________________________= __________

Address of Company: ___________________________________________________________________________= ________

Phone #:______________________= ____ Supervisor: _________________________________________

Dates Employed: From ___________To____________Reason for Leaving____________________________________________________________________= _____________________

Military Service: <= /o:p>

Branch of Service: _____________________________ Discharge Date: ___________________________

National Guard / Reserve: Yes ________ No _________ Date obligation ends: ______________________

Special training received: _________________________________________________________________

References

Name: _____________________________________________ Relationship: _______________________

Phone No: (H) _____________= (W) _______________ (Cell) _____________ (Pager) _______________

Name: _____________________________________________ Relationship: _______________________

Phone No: (H) _____________= (W) _______________ (Cell) _____________ (Pager) _______________

Name: _____________________________________________ Relationship: _______________= ________

Phone No: (H) _____________= (W) _______________ (Cell) _____________ (Pager) _______________

I acknowledge that the Dist= rict is relying on the information given and I certify that the information on this application is true to the best of my knowledge. I authorize the District to obtain information from any person named above and I release all concerned from any liability in connection with obtaining and releasing such information.

Signature of Applicant: ___________________________________________ Date: __________________

For District Use Only

Date Application Received=

Date Requested

Date Received

Drug Test Results

Driving Background Check<= /p>

Criminal Background Check=

Date Application Received=
	Date Requested	Date Received
Drug Test Results
Driving Background Check<= /p>
Criminal Background Check=