Firefighter For A Day - City of Novi

Name (*)

Address (*)

Email Address (*)

Phone (*)

Date of Birth (*)

Drivers License Number (*)

Resident of (*)

How long (*)

Explain Briefly why you wish to be enrolled in the Firefighter for a Day program (*)

Have you ever been arrested for, convicted of, or cited for an offense other than traffic fines of $200 or more?:

If yes, please explain:

List two immediate family members / close friends that can be notitified in the case of an emergency.

Emergency Contact 1 Name (*)

Emergency Contact 1 Relationship (*)

Emergency Contact 1 Address (*)

Emergency Contact 1 Phone (*)

Emergency Contact 2 Name (*)

Emergency Contact 2 Relationship (*)

Emergency Contact 2 Address (*)

Emergency Contact 2 Phone (*)

Please review your answers carefully and read the statements below before submitting this application.

I hereby certify that there are no willful misrepresentations, omissions or falsifications in the forgoing statements and answers to questions.

I understand that any omission or false statements on this application shall be sufficient cause for rejection for enrollment or dismissal from the Novi Firefighter for a Day Program.

Yes

I understand that space is limited and application does not guarantee acceptance to the program. By submitting this application, I request that a member of the Novi Fire Department contact me with any further questions, prior to this on-line application being approved.

Yes