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Online Application for the Dalhart Volunteer Fire Department.


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

Section 1: Personal Information
Name* (First & Last)
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*
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.
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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