1. Name:

2. Date of birth:

3. Place of birth:

4. Height:

    Weight:

    Hair Color:

    Eye Color:

5. Marital Status:

6.Do you have                     children?:

7. Would you agree to a back ground check:

8. Do you have any  known physical restriction ?:

If yes,explain:

9. Would you submit to a physical examination if required:

10. List your personal physicians name, address, and phone number:

11. When was your last physical?:

Was everything all right? (If not explain):

12. Do you have: respiratory problems:

Known heart problems:

Any back problems:

Any foot, ankle, knee, or leg injuries or problems:

Wear glasses, contact or hearing aid:

13. Are you bothered by: Heights:

Sight of blood:

Physical injury:

Death:

14. Do you take prescription drugs?:

15. Furnish an accurate statement of your employment record for the past 5 years. ( list the  name, address, job title, length of employment, reason for leaving):

16. Education level finished and degree:

17. Do you have any knowledge of foreign languages? (speak, read or write):

18. List three (3) persons, other than relatives or employers, who may be contacted:

 reference #2:

 reference #3:

19. Names and phone number of two people to contact in case of an emergency::

 contact # 2:

20. You social security number (Not Required on-line):

21. Drivers license number and classification (Not Required on-line):

Explain any notations or violations:

Are you willing to obtain a class "B non CDL" Illinois drivers license:

22. Mililitary Service:Date, Branch, Rank at discharge, Type of Discharge, Citations Etc.:

23. List any information which you feel will aid you in qualifying for this position, such as special training or abilities:

24. You must discuss the Fire Department with your spouse, what are their feeling toward your becoming a member:

25. lf work and health permits, are you willing to attend training session and schooling:

It is understood and agreed that any agreement entered into between the Prophetstown Fire Protection District and the applicant is predicated upon the truthfulness of the statements herein contained.
Applicant's Name:

Spouse's Name:

Address:

Phone number:

Date:

E-Mail address: