BRUSH VOLUNTEER FIRE DEPARTMENT 

Membership Application 

The information you provide in this application will be used in determining suitability for the position of Firefighter. Please complete the questionnaire entirely, keeping in mind that: 

• Completion of the entire application is mandatory 
• All statements are subject to verification 
• Inaccuracies or incomplete statements may cause your application to be rejected and your name to be removed from further consideration 
• All time periods in your background must be account for 
• Include both day and night contact for all references you list. 

It is to your advantage to be timely and open in your response. Any negative factor in your background will be evaluated in terms of circumstances and facts surrounding the occurrence and its degree of relevance to the position you are applying for. The investigating official will inquire into the facts surrounding the occurrence. Any evaluation will then be made on the relevance of these facts to the requirements of the position. 

Please print in ink or type your response to this questionnaire. If a question does not apply to you, write "N/A" (not applicable) in the space provided for your response. Do not leave any portions blank. If you need more space than provided to respond to the question, use the reverse side of the page and identify the additional information by the question number. Any questions concerning the application should be directed to one of the following department 

trustees: 

Zach Peterson (970)768-1784 

Tristan Dory (970)380-5788 

Colin Dupre (970) 286-3681 

Applications for current vacancies must be received by the Brush Volunteer Fire Dept., P.O. Box 6, Brush CO 80723 and postmarked within 30 days of the date the application was received in order to be considered. 

The Brush Volunteer Fire Department is an Equal Opportunity Agency. We prohibit unlawful discrimination against applicants or members on the basis of age, race, sex, color, religion, national origin, disability, genetic information, or any other applicable status protected by state or local law. 

Prior to extending an offer, each candidate will be interviewed and pass a physical agility test. If the candidate is then extended an offer to join as a Firefighter, that offer will be conditional upon successfully passing and completing physical examinations and background investigations. 

If selected, you may be required to provide proof of eligibility to work within the United States.

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Applicant Name

Last (required)

First (required)

Middle (required)

Date (required)

Home Phone Number

Work

Cell

Email Address (required)

Referred by (BVFD current member name)

Have you ever applied with the BVFD before?

If yes, when?

Have you ever been a member of the BVFD before?

If yes, when?

Have you ever been convicted of a crime? (A criminal record does not automatically bar you from membership)

If yes, provide details

Do you have a current valid Driver's License? (required)

Yes

No

Do you have a current Commercial Driver's License? (required)

Yes

No

Driver's License Number (required)

Exp. Date

State

Class

Name as it appears on the Driver's License

Last

First

Middle

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EDUCATION/CERTIFICATIONS

Type of SchoolHigh SchoolCollege (Undergraduate)College (Graduate)Trade School

Name, City & State

# of years Attened

Did you Graduate?

Yes

No

List Degree and/ or Area of Concentration

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EMT-B/P (if applicable)

Date

Expiration

Current CPAT

Yes

No

Date

Other knowledge, skills, and abilities relevant to the position for which you are applying: (i.e.: apprenticeships, correspondence course, or other special training not listed above)

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PERSONAL AND PROFESSIONAL REFERENCES

Do you currently have any relatives working for the Brush Volunteer Fire Dept?

Yes

No

If yes, please list name and relationship

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List references, three individuals who have knowledge of you and your qualifications

Name of Acquaintances

Company & Title or Location

Relationship to you

Telephone Numbers D=Day, N=Night

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Work History (List the last four places you have worked)

Month/YR Started

Employer

Position

Reason for Leaving

Month/YR Ended

Address and Phone Number of Employer

Supervisor

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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Thank you, your submission has been received.

All information provided by me is true and correct to the best of my knowledge. I understand omissions. or misrepresentations may result in rejection of my application or if employed, may result in subsequent dismissal. I hereby authorize all former employers, educational institutions, personal references and others identified hereon, including their employees or representatives, to furnish or provide full and complete reports, documents or information to the Brush Volunteer Fire Dept / City of Brush or its representative concerning my prior educational and work histories, criminal and driving records, or other information I have provided hereon. I waive, release, indemnify and hold harmless the BVFD / City of Brush or its employees and representatives and all other persons or entities from all liability and claims of any nature whatsoever pertaining to the disclosure or use of information or written material as described above. I understand this is a preliminary application and not a contract of membership or employment. Furthermore, in the event I am selected, my employment shall be completely voluntary and may be terminated at any time by myself or the BVFD / City of Brush.