Your Name

Your Name

Last Name

First Name

Middle Initial

Address

Address

Street Address

City

Zip

Contact Information

 *

Contact Information

Home phone

Cell phone

Email address

Personal Information

 *

Personal Information

Social Security Number

Date of Birth

DL Number

DL State

Emergency Contact Information

Emergency Contact Information

Name	Relationship
Address	Phone

Polo Shirt Size:

Polo Shirt Size:

XS	S	M	L	XL	XXL
Mens	Womens

Please review your answers carefully and read the statement below. Submission of this form serves at your signature.

I certify that all statements made on this application are true and complete and there are no willful misrepresentations, omissions, or falsifications in the foregoing statements or answers to questions. I understand that any omissions, falsification, or misrepresentations shall be sufficient cause of rejection for enrollment in, or dismissal from, the Hurst Citizens Fire Academy. I further understand that the Hurst Fire Department will conduct a background investigation that will include, but not be limited to, employment history and personal references.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

Page 1 / 1