Urban Search and Rescue Task Force Member Application
Items in bold are required.
Personal Information
Position Applying For: STUCTURES SPECIALIST
Last Name:  
First Name:  
Middle Name:  
Home Address 1:  
Home Address 2:
City:
  State:     Zip:  
     
Telephone: (Primary):
 
 
Telephone: (Secondary):
 
Email:
DOB:
 (mm/dd/yyyy)
 
SSN:  (last 4 digits)  
DLN:
  State:     Class:     Expiration Date:  
    
Have you ever received a traffic violation?:
 If yes, enter details below:
Have you ever been convicted of a felony?:
 If yes, enter details below:
Are you a US citizen?:
 If no, enter status below:
 
Employment History
Current Employer:  
Position:  
Start Date:  
Have you been employed under other names?:
 If yes, enter other names below:
Military
Branch:
Dates of Service:
Rank at Discharge:
Type of Discharge:
Discharge Date:
Duties/Special Training:
High School
School Name:  
Location (City/State):  
Date Graduated/GED  
College/University
College/University:
Attended/Location
From Mo/Yr:
To Mo/Yr:
Units Completed:
Sem. Qtr.
Major:
Degree:
Year:
 
College/University:
Attended/Location
From Mo/Yr:
To Mo/Yr:
Units Completed:
Sem. Qtr.
Major:
Degree:
Year:
 
College/University:
Attended/Location
From Mo/Yr:
To Mo/Yr:
Units Completed:
Sem. Qtr.
Major:
Degree:
Year:
Special Training
Institution-Business:
Trade School
Course:
From Mo/Yr:
To Mo/Yr:
Hours Completed:
Institution-Business:
Trade School
Course:
From Mo/Yr:
To Mo/Yr:
Hours Completed:
Licenses & Registrations:
License/Registration:
License State & Number:
Issued By:
Expiration Date:
 
Certifications:
Select Certifications:
Do you know a foreign language?:
 If yes, enter details below:
Additional skills, special training or related courses.
Include any other information relevant to your
employment application.
Miscellaneous Fire District Information:
Would you be interested in the Residency Program?
How did you hear about Boone County Fire Protection District?
Have you ever served on an emergency services organization?
(EMS, Fire, Law Enforcement...)		  If yes, enter details below:
List the names of any firefighters that you know that are currently on or have been a member of Boone County Fire Protection District:
Name:
Station:
Name:
Station:
Name:
Station:
References:
List three persons who are NOT related to you and who have definite knowledge of your qualificatoins and fitness for the position for which you are applying. Do not repeat names of supervisors listed under Employment History.
First Name:  
Last Name:  
Present Business/Home address
(Number, Street, City, State, and Zip:		  
Relationship:  
Telephone Number:  
 
First Name:  
Last Name:  
Present Business/Home address
(Number, Street, City, State, and Zip:		  
Relationship:  
Telephone Number:  
 
First Name:  
Last Name:  
Present Business/Home address
(Number, Street, City, State, and Zip:		  
Relationship:  
Telephone Number:  
 
Why do you want to become a STUCTURES SPECIALIST for the Boone County Fire Protection District:
 
PLEASE READ CAREFULLY AND CHECK THE BOX BELOW. The above information is true and complete, and I understand that any false information or omissions will be grounds for a refusal to hire me, or immediate discharge if hired. The Boone County Fire Protection District may review my previous employment, driving and criminal records, and other background data as it may relate to the positions(s) for which I am applying.

®2013 Boone County Fire Protection District, Columbia, Missouri