Memphis Volunteer Fire Department

Serving the City of Memphis, Townships of Columbus, Richmond, Riley, and Wales

MEMPHIS FIRE DEPARTMENT APPLICATION
NAME:_______________     PHONE:_____________    SOCIAL SEC. # ______________
ADDRESS:___________________________________    HOW LONG:____________
PRIOR ADDRESS:____________________________    HOW LONG:_____________
SEX: __________    HEIGHT:__________    WEIGHT:_________    DATE OF BIRTH:_______________
DO YOU OWN OR RENT YOUR HOME:__________________________

PHYSICAL HISTORY
LIST ANY PHYSICAL LIMITATIONS (Such as eyesight, limb limitations) 
______________________________________________________________________________

______________________________________________________________________________

EXPERIENCE AND QUALIFICATIONS 
 
HAVE YOU EVER BEEN A MEMBER OF ANOTHER FIRE DEPARTMENT:  ______ Yes    _____ No
IF YES:  _____________________ DEPT. NAME   _____________________ CITY  _____________  STATE____________ 
SHOW ANY SPECIAL COURSES THAT WILL HELP YOU AS A FIREMEN:____________________________________________________________________________
_____________________________________________________________________________________ 

it is agreed and understood that any false statements given above will be an act of dishonesty.                This certifies that the application was completed by me, and that all entries on it and information                 in it are true and complete to the best of my knowledge. 

DATE:________________________          APPLICANT SIGNATURE:_____________________________

This form must be printed and then completed before being submitted to the city office.