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2. Full Name: *
4. Address1
6. Address2
8. City
9. State
10. Zip
12. Phone Number*
14. Email Address*
16. Employer*
18. Social Security Number*
20. Date of Birth*
22. Texas Drivers License*
24. How did you hear about us?
26. Shirt Size

    1. Small
    2. Medium
    3. Large
    4. Extra Large
    5. 2 X
    6. 3 X
28. Background Check*

    1. I agree that a criminal background check will be conducted

    By checking the above box, I understand the Roanoke Fire Department will verify the above information. I also understand and agree that a criminal background check will be conducted. A criminal history may disqualify me from being selected to attend the Roanoke Citizen’s Fire Academy and ride-along program.

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30. 1. Receive an email copy of this form.
31. Email address

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32. Submit

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