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2. Section 1: Personal Information
4. First Name
5. Last Name
7. Address 1
9. City
10. State
11. Zip Code
13. Address 2
15. City
16. State
17. Zip Code
19. Sex

    1. Male
    2. Female
21. Driver License Number
22. Driver License State*
24. Driver License Expiration Date*
25. Driver License Class*
27. Date of Birth*
    Date of Birth
28. Social Security Number*
30. Height*
31. Weight*
33. Marital Status

    1. Single
    2. Married
    3. Separated
    4. Divorced
    5. Widowed
34. Full Name of Spouse and Age
35. Full Name of Spouse and Age
37. Section 2: General Information
39. Years of Education Successfully Completed
    -- Select One --56789101112College
40. If College, Degree or Hours
42. Have you been a member of any other Fire Department?*

    1. Yes
    2. No
43. If Yes, state where?
45. When can you respond to a toned call (Click 1 or both) ?*

    1. Day
    2. Night
46. Do you Live within City Limits of Dalhart or response time of 5 minutes or less?*

    1. Yes
    2. No
48. Indicate any crime or misdemeanor for which you have been convicted. Omit Minor Traffic violations.
50. Section 3: Employment Information
52. Give a Complete account of your present and past employment
54. Current Employment*
55. Employment 2
56. Employment 3
58. How does your Present employer feel about you being a member of the Fire Department?*
60. Section 4: Medical Information
62. Name & Address of Personal Physician*
64. Medication Currently Being Taken*
66. Date & Reason for last Visit*
68. Family Medical History*

    1. Nervous or Mental Illness
    2. Diabetes
    3. Tuberculosis
    4. Other
    5. None
69. If selected Other, please describe
71. In the {ast 2 years, have you ever missed work due to an injury or sickness, including colds, flu, ect?*

    1. Yes
    2. No
72. If yes, what was the Frequency, duration and reason for these occurrences.
74. Do you have any injury, illness, defect, deformity or disease which may interfere with your ability to perform your job on the Department?

    1. Yes
    2. No
75. If yes, please explain
77. 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.

79. Signature*
80. Date*

82. 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.

84. Do you Agree?*

    1. Yes
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86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit

* indicates a required field