APPLICATION

BONHAM FIRE DEPT

2091 JONESVILLE HWY

UNION SC 29379

DATE OF APPLICATION--------------------------                S.S.N--------------------------------------------------

            [FIRST]                                                                           [MIDDLE]                                                                                      [LAST]

NAME--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

ADDRESS----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

DRIVER  LIC. NUMBER------------------------------------------------------------------------------------------------------------------------------------------------------------------

D.O.B-----------------------------                          SEX----------------------                         HEIGHT----------------------                           WEIGHT--------------------------

MARITAL STATUS------------------------------------------------------                                                NAME OF SPOUSE------------------------------------------------------

PHONE# [HOME]-------------------------------                                 [WORK]-----------------------------                                         [CELL]-----------------------------------

EMPLOYER NAME-----------------------------------------------------------------------------------------------------------------------------------------------------------------------

ADDRESS----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

SHIFT WORKED-----------------------------------------                                                                              CAN YOU LEAVE WORK?---------------------------------------

IN CASE OF EMERGENCY WHO SHOULD WE NOTIFY--------------------------------------------------------------------------------------------------------------------------

ADDRESS---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

PHONE#--------------------------------------                                                                                               RELATIONSHIP--------------------------------------------------

PLEASE LIST 2 REFERENCES OTHER THAN FAMILY------------------------------------------------------- ---------------    ----------------------------------------------------

HAVE YOU EVER BEEN CONVICTED OF A CRIME OTHER THAN A MINOR TRAFFIC VIOLATION IS SO PLEASE EXPLAIN----------------------------------------

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DO YOU HAVE ANY PREVIOUS FIRE EXPERIENCE IS SO WHEN AND WHERE----------------------------------------------------------------------------------------------

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PLEASE READ CAREFULLY AND SIGN

I CERTIFY THAT ALL STATEMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND HERE BY AUTHORIZE THE BONHAM FIRE DEPT TO CONDUCT WHATEVER BACKGROUND INVESTIGATION IT DEEMS NECESSARY TO CONFIRM ANY STATEMENT SUBMITTED HEREIN I ALSO UNDERSTAND A SLED BACKGROUND CHECK WILL BE PREFORMED.

SIGNATURE--------------------------------------------------------------------------------EMAIL ADDRESS--------------------------------------------------------------------------

DATE--------------------------------------

CHIEF SIGNATURE------------------------------------------------------------                                                             HELMENT NUMBER------------------------------------

PROBATION PERIOD-----------------------------------                                                 -TO                                      ------------------------------------------------------------