Employment Registration Form – Bennington Fire & Rescue

Employment Registration Form

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Application Information

First Name:

Middle Inital:

Last Name:

Phone:

Email:

Address

Street Address Address Line 2 City State ZIP Code

Are you a citizen of the United States?

Yes

No

You must be over the age of 19 to apply. Are you over the age of 19?

Yes

No

Do you have State of Nebraska Firefighter I certification?

Yes

No

Do you have a State of Nebraska EMT/Paramedic license?

Yes

No

Level of Licensure:

Military Service

Have you served in the United States military?

Yes

No

Branch:

From (Month/Year):

To (Month/Year):

Rank at Discharge:

Type of Discharge:

If other than honorable, please explain:

Disclaimer and Signature

By signing below, I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature:

Today's Date:

MM slash DD slash YYYY

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