Dade County First Responder Application

Name:

DOB:

Age:

Address:
Work Phone:

Home Phone:

Cell Phone:

Email Address:

DSN (if already assigned)

Employer:
Hours/Days Worked:
Social Security #:
Married:
Single:
Children: Yes No

Drivers License:
Name of spouse:

Do you have a felony arrest record: : Yes No

Do you have any traffic violations: : Yes No

If yes please explain:

What kind:

Insurance Company/Agent:
Do you have any medical experience? If so what kind and when:

Would you be able to attend training on meeting nights? : Yes No

Would you be able to attend training away from the county: Yes No
Do you have any medical complications that may interfere with doing assigned activities at an
incident scene?
Yes No

If yes please explain.

Emergency Contact Name/Number:

Doctors Name/Address:

Effective 11/12/2016

Hospital preference:
I release the Dade County First Responder group to do any background or criminal record check necessary
to verify my credibility. I swear all of the above information is true, and I understand that if any
falsification or inconsistencies develop in my background investigation, I may be denied a position with
this organization.

Applicant:
DCFR Chief:

Effective 11/12/2016