Information And Application Packet Page 8

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Texarkana College
Fire Academy
Application
Personal Information
Name:
_______________________________,
____________________________ _______
Last
First
MI
Address: ______________________________________________________________________
Mailing Address
_________________________________________
_________
______________
City
State
Zip
Phone:
(______) ______-__________
Email: ____________________________________
Date of Birth _________________
Academy Start Date Requested ____________________
TCFP Pin #: __________________________ Social Security # ___________________________
Emergency Contact
___________________________________ _________________ (______) ______-__________
Name
Relationship
Phone
Highest Educational Level Attained
GED
 High School Diploma  Some College
 Associates Degree
 Bachelor Degree
 Graduate Degree
Fire Service Affiliation (Mark all that apply)
 None
 Paid Firefighter – Department
_________________________________________
 Volunteer Firefighter – Department ______________________________________
Emergency Medical Certification
 None
 First Responder
 EMT-Basic
 EMT-Intermediate
 EMT-Paramedic
Current
 Expired
 Currently Enrolled
Status -
 Not Applicable
Sponsoring Fire Department
____________________________________________  Paid  Volunteer  Combination
Department Name
______________________________________________________________________________
Address
City
State
Zip
_____________________________________
____________________________________
Fire Chief
Phone

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