| Emergency Firefighter Application Fire Year________ |
PRINT ALL INFORMATION PLEASE |
| NAME___________________________________________ SOCIAL SECURITY NUMBER____________________ |
| PERMANENT MAILING ADDRESS_________________________________________________________________ |
| TELEPHONE NUMBER_________________________MESSAGE PHONE NUMBER_________________________ |
| ARE YOU (OR YOUR SPOUSE) AN ENROLLED MEMBER OF AN INDIAN TRIBE OR A DESCENDANT?______ |
| YOUR TRIBE_____________________________________SPOUSE'S TRIBE_______________________________ |
| YOUR DATE OF BIRTH________________________AGE___________WEIGHT____________HEIGHT________ |
| EMERGENCY NOTIFICATION NAME AND TELEPHONE NUMBER____________________________________ ______________________________________________________________________________________________ |
| HAVE YOU EVER BEEN CONVICTED OF A FELONY?____________________________________________ |
| DO YOU HAVE ANY ALLERGIES TO INSECTS?_________________TO ANY MEDICATIONS?_____________ |
| DO YOU GET CLAUSTROPHOBIA?____________________________OTHER?____________________________ |
| ARE YOU CURRENTLY UNDER A PHYSICIAN'S CARE?_____________________________________________ |
| LIST ANY PHYSICAL PROBLEMS________________________________________________________________ |
| DATE OF LAST PHYSICAL EXAM________________________________________________________________ |
| HAVE YOU RECIEVED CAMP CREW TRAINING?___________________________________________________ |
| LIST ANY SPECIAL SKILLS YOU HAVE(ex: forklift driver, radio operator)_________________________________ |
| HAVE YOU PASSED THE PHYSICAL FITNESS TEST? (The 'Pack Test' is mandatory)________________________ |
| DATE TAKEN_______________TIME______________WHO ADMINISTERED TEST?_______________________ |
| By applying for hire as part of the Quinault Emergency Firefighter Crew, I understand that upon hire I will be bound by the Code of Conduct which I have read and signed. I also understand that a Drug Screen Urinalysis test is mandatory with Negative results as a condition of hire. Further, I understand that when I am hired I will be issued equipment for which I am personally responsible. Therefore, I agree that the Bureau of Indian Affairs can at their discretion hold a $100.00 Equipment Deposit from my pay. This deposit is refundable to me when I return all equipment I was issued. |
| SIGNATURE______________________________PRINT NAME__________________________DATE____________ |
| Mail application to: Quinault Nation Fire Management, P O BOX 189, Taholah, WA 98587 |
| OR Drop it off at our office at: Quinault Dept. of Natural Resources, 1214 Aalis Dr Bldg C, Taholah, WA 98587 |
| If you have any question call: Quinault Nation Fire Management Office at: (360) 276-8215 extension 284, 289 or 387 |
| WE ARE LOOKING FORWARD TO HAVING YOU ON OUR CREW! |