JOIN US TODAY “There will never be a right time. Stop waiting and start doing.” - Mel Robbins APPLICATION Name * First Name Last Name Phone * (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country How long have you lived in Bacliff, TX? Social Security Number * Date Of Birth * MM DD YYYY Age Type Of Membership * Firefighter First Responder Auxiliary / Support Highest Education Level * Special Studies Last School Attended * Employed By * Position * Company Phone Number * (###) ### #### Employers Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Why do you want to join the Bacliff Volunteer Fire Department? * General Health Status * Excellent Good Fair Poor Blood Type * AB+ AB- A+ A- B+ B- O+ O- Allergic to any medications? * Yes No If yes, explain Medical Conditions elect Medical Conditions that Apply Heart Trouble High/Low Blood Pressure Vision (Non-Correctable) Diabetes Respiratory Trouble Hearing Alcoholism Drug Abuse Mental Others Not Listed Have you been under Doctors care within the last three (3) years? * Yes No If yes, explain List any regular medications Current Physician First Name Last Name Physicians Phone Number (###) ### #### Are there any warrants currently against you? * Yes No Have you ever been convicted of a felony offense? Yes No Do you have fire service or medical experience? * Yes No Email If yes, Department Name If yes, date joined MM DD YYYY If yes, reason for leaving If yes, highest rank attained: If yes, Superior Officer Name: First Name Last Name If yes, department phone number: (###) ### #### Have you ever been refused admittance to, or discharged from any part of the Fire or EMS services: * Yes No If yes, please explain: List of any special service skills or training: Do you affirm all information submitted above is true and accurate at time of submitting? * Yes Thank you! A recruiter will be in contact in the next 24 - 48 hours.
