City of South Bay Fire Dept

City of South Bay Fire Department

Reserve Program Application

Name ______Date______

Address ______City______

Home Phone ______Cell ______Other ______

D.L # ______Height ______Weight ______Hair ______Eyes ______

S.S #______DOB ______Place of Birth ______

(City & State / or Country)

References (do not use relatives)

1)______Address ______

Phone______Years Known ______

2)______Address ______

Phone______Years Known ______

3)______Address ______

Phone______Years Known ______

Background Information

A)  Have you ever been arrested? Y__ N __ if yes explain where and why? ______

B)  Have you had your driver’s license suspended or revoked? Y___ N____ If yes explain where and why?______

C)  List all traffic citations received in past 3 years ______

Required documents: Office use only:

Drivers License _____ Valid ______Initials ______

High School Diploma or GED _____ Valid ______Initials ______

State FF I or II Certificate _____ Valid ______Initials ______

CPR Card _____ Valid ______Initials ______

EMT Card (optional) _____ Valid ______Initials ______

EVOC Certificate _____ Valid ______Initials ______

Completed Medical form _____ Valid ______Initials ______

Drug Screen _____ Valid ______Initials ______

(Have screening agency send SBFD results)

I ______, in return for recognition with the Florida State Fire Marshals Office and to maintain my reserve status as a member of the South Bay Fire Department, will do the following

A: Complete all training and assignments assigned to me in a proficient manner.

B: Will complete a minimum 48 hours of scheduled shift time each month (consisting of at least two 24 hour periods) to gain recognition as a Firefighter with the City of South Bay.

C: Will represent the City in the most up most and professional manner at all times.

By signing this I agree with and understand what is expected of me and will do my best to fulfill theses expectations.

Print Name______Date______

Sign name ______

Applicant Approved by Captain: Yes ______No ______Date ______

Applicant Approved by Chief: Yes ______No ______Date ______

JRF Aug/05