HARTFORD FIRE DEPARTMENT

APPLICATION FOR FIREFIGHTERS

Position Applied for:

(Type or print in Ink. Application not properly filled out will not be accepted;
they may be rejected or returned for correction).

1. Name
FIRST
HMIDDLE INITIAL LAST

2. Social Security Numb

3. Current Address
Number/Street/Apt. #

4. How long at this address

5. Give address, fftr past 10 .Ye

6. Date and place of birth

7. Are you a citizen? If naturalized, give date

8. Height (without shoes) p Z weight ~ZZ& eye

9. Marital status Number of dependants

10. General physical condition. Poor Good Excellent

Describe any health problems, or limitations that would affect the position
you are applying for

r
11. Have you ever received State Workmen's Compensation?
iwer is yes, give details. Nature of injury, office where claim was filed, etc.

12. Do you have valid driver's license(s)? State QT~ Oper.# JB sm^^ •
13. Do you have any civil litigations pending for/against you at this time?
Describe: OiHOd ChUO ^XXYyH-! iA&&mrnc^

14. MILITARY DATA (Armed Forces - United States)

Military record (A j , Service and Branch: L).cV

Selective Service Date Entered:
Date Discharged
Type of Discharge : f>. Final Rank
Have you or are you drawing any type of disability pay?
From what agency? Reason

15. Can you speak, read or write any language other than English?
Describe which language(s)
Good Fair Poor Speak Read Write

16. Are you addicted to liquor ? Illegal Drugs?

Do you drink alcoholic beverages? kit") . If so, how often and how much
per week? ^Jcy. Do you use any illegal drugs?
When was the last time you used illegal drugs?
Do you gamble? kCo. How often? kip. How much?

17. Do you know of anyone who may try to injure you in any way and why?

18. Have you ever been convicted of a criminal offense? ByS, Do you have any cases
Pending before the Court? KJO. If you answer yes to either question, please give
Date, location, charge, and disposition J Z t o l 9 ^ Gt . B . t4 for ThrQqign tq
UtQ . of- RroTecri^je order

19. Are any of your relatives in the firefighting service (government or volunteer)? NJD
If yes, indicate name, relationship and agency
 20. List all community, social, charitable, service or other organizations you have
belonged to in the past 3 years. Describe offices held or other leadership positions,
if any.

Name and Address of Organization Activity/Position

1. fordghftre. ffiranr£teifj , cr MoiorrteF

2. V[nf. ffircmfteifi Rnnb'ipfrg.l qplurrVw
3.

EDUCATIONAL DATA

Name and address Dates Type of diploma Course or Number

of school Attended Certificate of Degree Subject of Credits

High Schools

Colleges

Other
Pf^rc UUnrfer t CT

What business, military, or other special training, apprenticeship, correspondence course,

etc., not shown above, have you had which you believe have helped you prepare for a career
in the position you are applying for:

Course Where Taken Dates Certificate

1. CrTnrnonicWiCA O-^> JRf

4.
(Attach copies of certificates, diplomas or other substantiating documents).
REFERENCES: Reliable persons other than relatives or past employers who you've
known for at least two (2) years.

NAME ADDRESS OCCUPATION

2- Miqqpr
3. m'iCL (2.

WORK HISTORY:

Present or last employer: May we contact your present employer? x(S

Employer name/Address: CjftYyiM.fgJi GnrOU19t&, -4 ^t Mt^n^ JOEdrY
Qb4lb — JMKiMMiiHtiZ^tS'
Phone:
Portion/Title: DitY^r / O7O^r Dates of employ mentTSfCg
Weekly. Salary;
•ttT~~ C_I
B(cD
.. GTly-vTV I t I I-—.r^ / / • «
Supervisor;
Reason for Leaving: 5tft f f t ( ro
General Duties: F)P,(.User < fQci

Employer name/AddressTyySTT("rv|ft ^ [4 OH (Al

_-,
Phone
Position/Title: Dnoer Dates of employment:
Weekly Salary: Supervisor:
Reason for Leaving: f^Vill
General Duties: StiTBH^'ytej Cno©T

Employer name/Address:
Phone:
Position/Title: Dates of employment:
Weekly Salary: Supervisor:
Reason for Leaving:
General Duties:

Employer name/Address:
Phone:
Position/Title: Dates of employment:
Weekly Salary: Supervisor:
Reason for Leaving:
General Duties: