| Check the department you wish to join: |
Fire |
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Rescue |
| Applicant Information |
| First Name: * |
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| Middle Initial: * |
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| Last Name: * |
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| Address Street: * |
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| Mailing Address (If Different): |
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| City: * |
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| State: |
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| Zip Code: * |
(5 digits) |
| Home Phone: * |
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| Cell Phone: |
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| Email: |
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| DOB: * |
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| Are you at least 18 years of age?: |
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| Driver's License Number and State: |
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| Have you ever been convicted of a traffic violation?: * |
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| Have you ever been convicted of any violation of the law?: * |
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| Do you have any physical restrictions?: * |
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| Have you had a major illness or been operated on in the last 5 years?: * |
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| If Yes To Any, Please Explain: |
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| Emergency Contact |
| Emergency Contact - First/Last Name: |
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| Relationship: |
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| Contact Phone: |
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| Address: |
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| Present Employer: |
| Employer Name: |
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| Employer Phone: |
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| Position: |
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| Fire/Rescue Experience: |
| Any Prior Experience?: |
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| If Yes, Previous Department: |
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| Previous Chief's Name: |
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| Do you have any certificates and/or licenses in the fire/rescue field? If Yes, please list: |
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| Personal References (name, address & phone number) |
| 1. Personal Ref. Name: |
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| 1. Phone: |
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| 1. Address: |
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| 2. Personal Ref. Name: |
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| 2. Phone: |
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| 2. Address: |
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| Other Information |
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I authorize the Town Of Casco, Maine to check my criminal background and verify employment history. |
