Evans Valley Fire District 8677 E Evans Creek Rd
Rogue River, OR 97537 (541) 582-0678 https://www.evfire.org/
Application for Volunteer

Applicant Information

What role(s) are you applying for:	☐ Firefighter ☐ EMS ☐ Civilian Tender Operator ☐ Station Support ☐ Auxiliary

Full Name:	Click or tap here to enter text.	Date:	Click or tap to enter a date.
Last	First	M.I.

Address:	Click or tap here to enter text.
Street Address	Apartment/Unit #

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City	State	ZIP Code

Phone:	Click or tap here to enter text.	Email:	Click or tap here to enter text.

Social Security No.:	Click or tap here to enter text.	Are you legally authorized to work in the US?	☐ Yes ☐ No

Have you ever been convicted of a felony?	☐Yes	☐ No
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Education

High School:	Click or tap here to enter text.	Address:	Click or tap here to enter text.

From:	Click or tap to enter a date.	To:	Click or tap to enter a date.	Did you graduate?	YES ☐	NO ☐	Diploma:	Click or tap here to enter text.

College:	Click or tap here to enter text.	Address:	Click or tap here to enter text.

From:	Click or tap to enter a date.	To:	Click or tap to enter a date.	Did you graduate?	YES ☐	NO ☐	Degree:	Click or tap here to enter text.

References

Please list three professional references.

Full Name:	Click or tap here to enter text.	Relationship:	Click or tap here to enter text.
Company:	Click or tap here to enter text.	Phone:	Click or tap here to enter text.
Address:	Click or tap here to enter text.
Full Name:	Click or tap here to enter text.	Relationship:	Click or tap here to enter text.
Company:	Click or tap here to enter text.	Phone:	Click or tap here to enter text.
Address:	Click or tap here to enter text.
Full Name:	Click or tap here to enter text.	Relationship:	Click or tap here to enter text.
Company:	Click or tap here to enter text.	Phone:	Click or tap here to enter text.
Address:	Click or tap here to enter text.

Current/Last Employment

Company:	Click or tap here to enter text.	Phone:	Click or tap here to enter text.
Address:	Click or tap here to enter text.	Supervisor:	Click or tap here to enter text.
From:	Click or tap to enter a date.	To:	Click or tap to enter a date.
Job Title:	Click or tap here to enter text.

Responsibilities:	Click or tap here to enter text.
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May we contact for a reference?	YES ☐	NO ☐

Fire and EMS Certifications

If applicable, check all your fire and EMS certifications
☐ NFPA Firefighter 1	☐ EMR	☐ ICS 100
☐ NFPA Firefighter 2	☐ EMT	☐ ICS 200
☐ NFPA Driver	☐ EMT- Advanced	☐ ICS 300
☐ NFPA Apparatus Equipped with a Pump	☐ EMT- Intermediate	☐ ICS 400
☐ NFPA Mobile Water Supply	☐ EMT - Paramedic	☐ ICS 700
☐ NFPA Fire Instructor 1	☐ ICS 800
☐ NWCG Firefighter Type 1
☐ NWCG Engine Boss
If your certifications are not from Oregon, what state issued them?	Click or tap here to enter text.

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

By signing below, I consent to the following:

A criminal background check

A check on my driver record

A pre-employment drug screen

A reference check and investigation into my employment history

Date:	Click or tap to enter a date.

How to Electronically Sign: Double click on the signature line to bring up the Add Signature Pop Up Window. You can then either type your first and last name, or you can use your touchscreen or mouse to hand write a signature in the block.

If you have trouble electronically signing, you may still submit the application electronically, and sign it by pen at a later time. If you’re submitting electronically, please note in the email that you intend to sign by pen.