Antonia Fire Protection District Board of Directors Clifton Lewis Fran Newkirk Preston Haglin 6633 Moss Hollow Road Barnhart, MO 63012 636-948-4433 Fax: 636-948-0540 Chief John H. Newsome Deputy Chief Glenn Nivens Larry Steinkamp VOLUNTEER APPLICATION (Please print) Name First Middle Last Age Address Street City Phone# State Spouse’s Name Any Health Conditions? Zip Married or Single How Many Children State Any Problems Do You Drink Intoxicating Liquors? Moderate In Excess References: Family Doctor’s Name Phone# Address Are you allergic to any medications? If yes, what kind? Have you ever been arrested, indicted or convicted? what. State disposition of the case(es). What do you think the Fire Department is? If yes, how many times and for What do you expect of the Fire Department? Why do you want to be a Firefighter? List any firefighting experience you may have Have you ever belonged to a Fire Department? Dates / Mo. to Yr. / Mo. Yr. If yes, what department Department Address Are you employed? Employer: Address: Phone# Date of Birth May we call for a reference? Yes or No / / Drivers license # Exp. Date Blood Type Medical Information Please list two emergency contacts: Name Address Relationship Phone# Name Address Relationship Phone# I certify that all statements made in this application are true to the best of my knowledge. I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for disqualification or dismissal. I hereby release employers, schools, law enforcement agencies and persons from all liability for any damage whatsoever that may ensue from furnishing the same to the Antonia Fire Protection District. Further, I understand and agree that my position as a volunteer is for no definite period and may be terminated at any time without any previous notice. Signature Date CONVICTION RECORD RELEASE (Print legibly and in ink) The information requested is for identification purposes and is required by police authorities to properly identify an applicant. All applicants must supply this information. Possession of a conviction record does not necessarily bar you from enrollment. Each case is considered individually with reference to the position for which you are applying. Applicants selected for positions which involve driving a district vehicle will have their driving records checked. Possession of a poor driving record may result in the refusal of application. Name: Last First M.I. List other names you have used, gone to school under, and/or worked under (including maiden name): Date of Birth: / / Social Security # - - Place of Birth: City State Present Address: Street Address City State Zip List any previous Missouri Address(es): I hereby certify that the above information is correct and authorize the release of my entire record to the Antonia Fire Protection District. Signature Date SUMMARY OF DUTIES AND RESPONSIBILITIES Under the immediate supervision of higher ranking officers, members in the classification are responsible for: 1. Preventing, containing and extinguishing fires. 2. Administering emergency medical service. 3. Assisting in rescue/evacuation operations under extreme conditions. 4. Maintaining and cleaning district equipment, apparatus, vehicles and facilities. 5. Driving and operating various types of fire apparatus safely. 6. Participating in and/or conducting fire prevention drill and training 7. Preparing and maintaining various files and records as directed. 8. Assisting in the inspection of buildings for fire hazards, compliance with fire prevention codes, and pre-incident planning. 9. Assisting in the investigation of fire cause and origins. 10. Maintaining excellent health and physical condition sufficient to permit full completion of assigned duties under often stressful and occasionally dangerous situations. 11. Performing related duties as needed and/or assigned. 12. Participating in or conducting various public relation/education sessions. programs.