Atlanta Volunteer Fire Department Firefighter Roster Form
PO Box 415, Atlanta, MO 63530. If you have questions regarding this form, please contact Aaron Baker at (660) 281-7777.
Your Current No.
Leave blank if not applicable. Example 807. Currently, 800 is Chief, 801 is Pumper, 802 is Tanker, 803 Brush Truck and 804 Pumper.
Your answer
Your Current Rank
Leave blank if not applicable.
First Name *
Your answer
Last Name *
Your answer
Middle Initial *
Your answer
Suffix
Ex: Jr. Leave blank if not applicable.
Your answer
Birth Date *
MM
/
DD
/
YYYY
Driver's License Number *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Email
Leave blank if not applicable.
Your answer
Home Phone
Leave blank if not applicable.
Your answer
Cell Phone *
Required
Your answer
Cell Phone Type
For use with our emergency phone app.
Education and Experience
Education Experience *
High School
Vocational School
College / University
Advanced Education
Type
Military Experience
Leave blank if not applicable. Please include Branch, Highest rank, Dates and Assignment.
Your answer
Fire / Rescue Experience
Leave blank if no experience outside of AVFD. If you have experience outside of Atlanta, please include Department name, city / state, rank and assignment.
Your answer
EMS Training
None
EMT
EMT-IV
Paramedic
EMR / First Responder
Type
Do you have any medical conditions that would prevent you from doing the physically demanding work of fire fighting? *
Type "no" if you do not have any medical conditions.
Your answer
Have you had a complete physical exam within the last two years? *
Date of last tetanus shot?
Type "unknown" if you do not know when your last tetanus shot took place.
MM
/
DD
/
YYYY
Allergies *
If none, please type NKA for "no known allergies."
Your answer
Have you reviewed the job desciprtion of a volunteer firefighter? *
Do you know of any reason you should not be able to serve at this time? *
Do you have a vehicle that you can drive to training sessions and emergencies? *
Do you carry liability insurance on all vehicles that you may drive while participating in fire department activities? *
Has your driver's license been revoked in the past five years? *
Do you have health insurance? *
Do you have any felony convictions or dui violations? *
Do we have your permision to run a background check? *
Are you willing to submit to a drug test? *
Your emergency contact's name, relationship to you and phone number: *
Your answer
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