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2. First Name*
3. Middle Initial
4. Last Name*
6. Date of Birth
   Date of Birth
7. Current Age
9. Address1
11. City
12. State
13. Zip
15. Home/Cell*
16. Work Phone
18. Email*
20. Reason for Request*
22. Have you previously participated in a ride-along with the Russellville Fire Department?

    1. Yes
    2. No
24. Have you ever been arrested?

    1. Yes
    2. No
26. I affirm that the information provided in this application is true and correct to the best of my knowledge.*

    1. I affirm
28. Digital Signature*
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30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field