City of South Bay Fire Department Reserve Program Application

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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

  1. Have you ever been arrested? Y__ N __ if yes explain where and why? ______________________________________________________________________________________________________________________________________________________________

  1. Have you had your driver’s license suspended or revoked? Y___ N____ If yes explain where and why?________________________________________________________________________________________________________________________________________________________

  1. 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

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