Brussels Union Gardner Fire Dept

Brussels – Union – Gardner Fire Dept.

Brussels, Wisconsin54204

South Station - #1 North Station - #2

1358 Cty DK 3116 N. Stevenson Pier Rd

Application for Volunteer Firefighter

(Incomplete Applications will not be accepted)

Last Name ______First Name ______Middle Name ______

Address______City______State _____ Zip Code ______

Gender (M=Male, F=Female) ______Are you over the age of 18? ____Yes ____ No

Telephone # (Home) ______/______/______Telephone # (Business) ______/______/______

Date of Birth ______-______-______Social Security Number ______-______-______

Valid Drivers License Number ______

Place of Employment ______

Address______City______State ______Zip Code ______

Supervisors Last Name ______First Name ______

Beneficiary of Insurance (to be completed upon hire)

Last Name ______First Name ______Middle Name _____ Relationship ______

Address______City______State _____ Zip Code ______

Please list Name of Schools attended and your levels of education

School ______City/State ______No. of years _____Year Graduated______

Please list any other skills you feel will be helpful to our department. ______

______

Current Training (IE: CPR, First Aid, etc.) ______

______

Please list any licenses, certifications, membership in professional organizations or other information you believe should be considered in evaluating your qualifications.

______

Have you ever been convicted of a Crime including misdemeanor, felony or any other crime? ______If yes, please explain______

______

References – Please list at least three

Name ______Number of years acquainted ______

Address ______

City, State, Zip ______

Telephone Number ______

Name ______Number of years acquainted ______

Address ______

City, State, Zip ______

Telephone Number ______

Name ______Number of years acquainted ______

Address ______

City, State, Zip ______

Telephone Number ______

Applicant - please read carefully and sign below

Information provided and statements made as part of this application may be grounds for not employing you or for dismissing you after you begin work. All information provided and statements made are subject to verification. All Applicants are subject to a background check.

Certification

All information provided and statements made by me as part of this application, or as part of any additional information provided in support of this application, are complete, correct and true to the best of my knowledge.

I understand that if I am employed, false information provided or false statements made as part of this application may be considered as cause for dismissal.

Signature ______Date ______

All applicants must have a valid drivers license.
All applicants must be permanent residents within the BUG FD Service Area.
Mail completed application to 1358 County Rd. DK Brussels, WI 54204