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2. Personal Information
4. First Name
5. Last Name
7. Date of Birth
   (MM/DD/YYYY)
8. Gender
   -- Select One --MaleFemalePrefer not to answer
10. Race/Ethnicity
    -- Select One --American Indian or Alaskan NativeAfrican American or BlackAsianCaucasian or White (Hispanic or Latino)Caucasian or White (Non-Hispanic or Non-Latino)Native Hawaiian or Other Pacific IslanderOtherPrefer not to answer
12. City
13. State
14. Zip Code
16. Phone Number
17. Email
19. Check yes if you would like to be included in our mailing list.

    1. Yes, Email and Postal Service
    2. Yes, Email only
    3. Yes, Postal Service only
    4. No
21. Referral Information
23. How were you referred to join RFD?
    -- Select One --Friend(s)FamilyRussellville Fire Department Facebook pageCity of Russellville Facebook pageOther Social Media PagePrint (Newspaper)TelevisionRadioRecruiting EventRFD RecruiterOther website

    If you have selected a Media, Recruiting Event, or Other Website, please indicate which below, then proceed to the Qualifying Information section.
25. Referral Details
27. Recruiting Event
    Please list the name or date of event
29. Media
    Please list the specific media venue (i.e., KARV, KCJC, River Valley Leader, Courier, etc.)
31. Other Website
    Please list the specific site or URL
33. Qualifying Information
35. Have you graduated from High School or obtained a GED?
    -- Select One --YesNoPrefer not to answer
37. College Hours you will have as of the Fall Semester
    -- Select One --0-3031-6061-9090 or morePrefer not to answer
39. Have you obtained at least 180 Days of Active Duty Military?
    -- Select One --YesNoPrefer not to answer
41. Have you ever been convicted of a felony?
    -- Select One --YesNoPrefer not to answer
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43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field