| NAME: |
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| DATE of BIRTH: |
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| ADDRESS: |
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| HOME PHONE: |
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| CELL PHONE: |
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| WORK PHONE: |
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| E-MAIL: |
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SEX |
MALE |
SEX |
FEMALE |
| MARITAL STATUS: |
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| SPOUSE'S NAME: |
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| CHILDREN - NAME-AGE BOY/GIRL: |
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| DRIVER'S LICENSE #: |
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| SOCIAL SECURITY #: |
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| EMERGENCY CONTACT INFORMATION: |
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| EMPLOYER: |
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| EMPLOYER'S PHONE #: |
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| EMPLOYER'S ADDRESS: |
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| HOURS YOU WORK: |
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| JOB DESCRIPTION: |
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| LAST GRADE OF EDUCATION COMPLETED: |
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| LENGTH OF RESIDENCE IN CANNON COUNTY: |
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| HAVE YOU BEEN CITED FOR A TRAFFIC VIOLATION IN THE PAST 3 YEARS: |
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| IF YES, PLEASE EXPLAIN: |
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| HAVE YOU EVER BEEN CONVICTED OF A CRIME: |
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| IF YES, PLEASE EXPLAIN: |
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| DO YOU HAVE ANY PHYSICAL HADICAPS? IF YES, PLEASE EXPLAIN: |
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| DO YOU HAVE ANY RESPIRATORY CONDITIONS? IF YES, PLEASE EXPLAIN: |
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| DO YOU HAVE A FEAR OF CLOSED SPACES?: |
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| DO YOU WEAR GLASSES: |
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| ARE YOU AWARE OF THE HAZARDS INVOLVED IN FIREFIGHTING: |
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| LIST ANY PREVIOUS FIREFIGHTING EXPERIENCE: |
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| LIST ANY CERTIFICATIONS HELD(FIREFIGHTING, EMS,RESCUE ETC.): |
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| WILL YOU BE WILLING TO ASSIST IN FUNDRAISERS: |
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| DOES YOUR SPOUSE HAVE ANY RESERVATIONS TO YOUR BECOMING A FIREFIGHTER: |
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| LIST 3 PERSONAL REFERENCES W/NAME,PHONE AND ADDRESS: |
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| NAME OF PERSON WHO RECOMMENDED YOU: |
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