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Online Application for the Dalhart Volunteer Fire Department.

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Any box marked with a * must be completed to submit application. 

Section 1: Personal Information
Name* (First & Last)
Sex*
Address 1* (Home)
Address 2 (Mailing)
Telephone # (Home)
Telephone # (Cell)
Telephone # (Work)
Driver License Number*
Driver License Expiration Date*
Driver License State*
Driver License Class*
Date of Birth*
Social Security number*
Height*
Weight*
Marital Status*



Full Name of Spouse and Age
Name & Ages of Children at Home
Section 2: General Information
Years of Education Successfully Completed*
If College, Degree or Hrs
Have you been a member of any other Fire Department?*
If Yes, state where
When can you respond to a toned call?* Click 1 or both

Do you Live within City Limits of Dalhart or response time of 5 minutes or less?*
Indicate any crime or misdemeanor for which you have been convicted. Omit Minor Traffic violations Date, Offense, Court, Disposition
Section 3: Employment Information
Give a Complete account of your present and past employment 
Current Employment* Name, Address, and dates employed
Employment 2 Name, Address, and dates employed
Employment 3 Name, Address, and dates employed
How does your Present employer feel about you being a member of the Fire Department?*
Section 4: Medical Information
Name & Address of Personal Physician*
Date & Reason for last Visit*
Medication Currently Being Taken*
Family Medical History* check 1 or Multiple




If selected Other, please describe
In the {ast 2 years, have you ever missed work due to an injury or sickness, including colds, flu, ect?*
If yes, what was the Frequency, duration and reason for these occurrences. Date, Type, Disability Length, Physician/Hospital, Workers Comp filed, Employers name & Address, any Permanent Effect
Do you have any injury, illness, defect, deformity or disease which may interfere with your ability to perform your job on the Department?*
If yes, please explain
Section 5: Certification
I, the undersigned, applying for the membership with the Dalhart Volunteer Fire Department, do hereby certify that the answers to the above questions are true and correct.  I understand that any false answers will be grounds for dismissal and I agree to hold the Department and/or the City of Dalhart blameless for such dismissal.  I also agree to undergo a physical examination, giving the examining physician permission to contact my personal physician, and allowing the examining physician to submit his findings to the Department, the Pension Board and/or the City of Dalhart.  Furthermore; I understand that this application is subject to approval by the Officers of the Department and Pension Board.
Signature*
Date*
By clicking "I agree," you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your "electronic signature" is valid and binding upon you to the same force and effect as a handwritten signature. 
Do you Agree? *

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