Membership Application COCKRELL HILL FIRE DEPARTMENT APPLICATION FOR MEMBERSHIP PERSONAL INFORMATION Name (Last, First, Middle) D.O.B. TX D.L. # Address City State ZIP Home Phone Mobile Phone Medical Issues Yes No Employer Work Phone EMERGENCY CONTACT #1 Name Relationship Home Phone Mobile Phone Address City State Zip Employer Employer Phone PROFESSIONAL REFERENCE (Not related to you) Name How do you know this person? How long have you known this person? Home Phone Mobile Phone Address City State Zip Employer Employer Phone AVAILABILITY Please Select Weekday Mornings Weekday Afternoons Weekday Evenings Weekend Mornings Weekend Afternoons Weekend Evenings INTEREST Please Select FIREFIGHTING - Responds to all calls within the city and provides mutual aid for neighboring cities. SUPPORT SERVICES - Responds to all structure fires and mutual aid calls to provide rehab, crowd control and traffic direction. FUNDRAISING - Helps establish and oversee all fundraising efforts for the department. FIRE PREVENTION - Teaches fire safety for schools or civic events. Participates in the Department’s Fire Starter Program. FIRE PREVENTION - Teaches fire safety for schools or civic events. Participates in the Department’s Fire Starter Program. S.O.P. / BY-LAWS - Creates and edits the Department’s Standard Operating Procedures and By-Laws. PUBLIC RELATIONS - Provides information regarding the Department to the public. Assists in fundraising and fire prevention while at events. Finds new recruits. EMS - Responds to all EMS calls within the city and provides mutual aid to neighboring cities. QUALIFICATIONS AND PREVIOUS EXPERIENCE LIST CERTIFICATIONS OR ANY EXPERIENCE THAT YOU FEEL WILL BENEFIT THE DEPARTMENT COMMENTS Were you referred by any Firefighter at CHFD? AGREEMENT AND SIGNATURE By submitting and signing this application, I confirm that the above statements are true and complete. I understand that my acceptance as a volunteer on this department is dependent on the results of a background check conducted by the City of Cockrell Hill Police Department and a positive vote by the members of the Cockrell Hill Fire Department as a whole. If I am accepted as a volunteer, any false statements, misrepresentations, or omissions made by me on this application may result in my immediate removal from the department. NAME Date Check The Box!