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Candidate Interest Card

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

Leave This Blank:


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