Fire Academy Application Palomar College Fire Academy Application "*" indicates required fields Step 1 of 2 50% Name* Last First Middle Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of Birth* Month Day Year Email* Phone*California Driver's License Number* Expiration Date* MM slash DD slash YYYY EducationHigh School*Location Year of graduation Degree or GED obtained? Yes No If you have ever had a Palomar College Student ID, please enter this 9-digit number Secondary Education Please list most recent institution first.College/University/ Other SchoolName and location Dates attended Degree Obtained ? Yes No College/University/ Other SchoolName and location Dates attended Degree Obtained ? Yes No College/University/ Other SchoolName and location Dates attended Degree Obtained ? Yes No PREVIOUS Palomar College Fire Academy applicantPlease check the box below if you applied for a PREVIOUS fire academy (not this one) and completed the application process, including the PAT and interview. Previous PC fire academy applicant Academy # Additional work experience or educationPlease LIST other related or unrelated experience/education or certifications you have completed that you feel would benefit the fire academy (no paragraphs, please). Employment InformationPlease LIST your most recent employment FIRST. Include all employment history, even if it is not related to the fire technology/medical field. Do not enter “See Resume.”1. Employer Name Address Street Address City State / Province / Region ZIP / Postal Code Position Description of duties/responsibilities (please list-no paragraphs)Supervisor Employer Phone NumberDates worked: FromMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ToMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Still EmployedCheck the box below if you are still employed by this employer Still employed Reason for leaving 2. Employer Name Address Street Address City State / Province / Region ZIP / Postal Code Position Description of duties/responsibilities (please list-no paragraphs)Supervisor Employer Phone NumberDates worked: FromMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ToMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Still EmployedCheck the box below if you are still employed by this employer Still employed Reason for leaving 3. Employer Name Address Street Address City State / Province / Region ZIP / Postal Code Position Description of duties/responsibilities (please list-no paragraphs)Supervisor Employer Phone NumberDates worked: FromMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ToMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Still EmployedCheck the box below if you are still employed by this employer Still employed Reason for leaving Physical conditions or limitationsDo you have any physical limitations that would prevent you from performing tasks involved in the Fire Fighter I Academy? Yes No If yes, please describe below:Conviction RecordHave you ever been convicted of a criminal offense resulting in imprisonment or probation? Yes No If yes, please describe below:Military Service Branch Rank Type of Discharge Enlisted dates: FromMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ToMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920California Driver's License*Upload your valid, current California Driver’s License hereMax. file size: 49 MB.Proof of High School completion*Upload your high school diploma or transcripts here. If you are submitting a college degree in lieu of your high school diploma/transcript, your college transcripts must show your college degree conferral.Max. file size: 49 MB.Current CPR card*Upload your current CPR card hereMax. file size: 49 MB.National Registry EMT*Upload your current NREMT or /NREMT-P license here. PLEASE DO NOT UPLOAD YOUR NREMT CERTIFICATE AS THIS DOES NOT REFLECT THE EXPIRATION DATE OF YOUR NREMT license. Max. file size: 49 MB.College TranscriptsUpload your college or university transcripts here. Max. file size: 49 MB.DD214Upload your DD214 (if applicable) here to show proof of military serviceMax. file size: 49 MB.Additional document uploadUpload additional documents such as proof of EMT employment, Explorer experience, letter of recommendation, etc. here. Drop files here or Select files Accepted file types: pdf, jpg, gif, png, doc, docx, Max. file size: 49 MB. Confirmation of complete application*By checking this box, I confirm that I have submitted ALL required and optional documents to my application, including EMT, CPR, CDL, and (if applicable) transcripts, DD214, proof of work/explorer experience. If you have pending transcripts or additional documents, you have until November 8, 2023 to email them to cmusgrove@palomar.edu I have submitted all required and optional documents Signature*I certify that my answers are true and complete to the best of my knowledge. I understand that any misrepresentation or omission of facts are cause for rejection of application and removal from the eligibility list for enrollment in the Fire Fighter I Academy. I hereby authorize the Palomar College administrator to investigate all statements contained in this application. I also understand that I will not receive points on my application if I do not include supporting documentation for education, certifications, work experience, etc. Δ
