Applications 2009 20th St, Nitro, WV 25143 304.755.1437 *protected email* HistoryContactApplicationCode Enforcement DivisionMetro 911Putnam 911City of Nitro Nitro Fire Department Application This form must be filled out in one sitting. You cannot save progress and return later to finish. Approximate time required: 15 minutes. The following required documents must be uploaded as part of this form. If you do not have a scan or clear photo of these documents ready, please leave and gather before returning to this form. Your valid Driver's License Your Social Security Card Your High School Diploma OR official GED Certificate Your Birth Certificate This application period ends September 10, 2026 at midnight. This form will go offline at that time. I confirm that I have enough time and scans of all required documents available and ready. * Yes About You First Name * Middle Name Last Name * Social Security Number * Date of Birth * Place of Birth * Are You a Citizen of the United States? * Yes No Contact Information Address * Address Address Address Address Address Address How long at this address? * Previous Address 1 Previous Address 1 Previous Address 1 Previous Address 1 Previous Address 1 Previous Address 1 Previous Address 1 Previous Address 2 Previous Address 2 Previous Address 2 Previous Address 2 Previous Address 2 Previous Address 2 Previous Address 2 Home Phone * Work Phone Cell Phone * Email * Spouse and Children Marital Status * Single Married Separated Widowed Divorced Spouse First Name Spouse Middle Name Spouse Maiden Name Spouse Occupation Spouse Employer Names and Ages of Children Driver's License DL State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY DL Number * DL Type * DL Expiration Date * Any Traffic Citations in the past three (3) years? * Yes No Citation Detail Military Military Service? * Yes No Branch of Service Date of Entry Date of Discharge Type of Discharge Reserve Status Unit Active or Inactive Active Inactive Education What do you have? * High School Diploma GED Name of High School Where You Graduated If GED, where obtained GED Date Obtained College/School 1 Start Date End Date Degree Obtained College/School 2 Start Date End Date Degree Obtained Medical Records Do you have any disease(s), physical or mental defect or disability in any degree? * Yes No Are you receiving or have you ever received disability income from any source? * Yes No Have you had any serious illness or injury or been confined to a hospital or had surgery in the past Three (3) years? * Yes No If ANY answer is yes to the above questions, explain Have you ever been or are you now being treated for any of the following (check all that apply)? * High Blood Pressure Diabetes Stomach Ulcers Nervous Condition Respiratory Problem None of the Above If Any answer is yes, please explain Name of Family Physician Physician Address Physician Address Physician Address Physician Address Physician Address Physician Address Physician Address Work History A. Present Employer or occupation * Employer A Address Employer A Address Employer A Address Employer A Address Employer A Address Employer A Address Employer A Address Employer A Phone Job Title Date Hired Supervisor B. Employer Employer B Address Employer B Address Employer B Address Employer B Address Employer B Address Employer B Address Employer B Address Employer B Phone Job Title Date Hired Supervisor C. Employer Employer C Address Employer C Address Employer C Address Employer C Address Employer C Address Employer C Address Employer C Address Employer C Phone Job Title Date Hired Supervisor D. Employer Employer D Address Employer D Address Employer D Address Employer D Address Employer D Address Employer D Address Employer D Address Employer D Phone Job Title Date Hired Supervisor E. Employer Employer E Address Employer E Address Employer E Address Employer E Address Employer E Address Employer E Address Employer E Address Employer E Phone Job Title Date Hired Supervisor Fire Service Experience Have you ever worked in fire service field before? Yes No If yes, list the agency(s) and address Explain or describe duties Legal Matters Have you ever been indicted, arrested, or convicted or questioned about your involvement in a criminal offense? Yes No If yes, list all information concerning each incident: Have you ever been a defendant in any civil action? Yes No List all civil actions in which you were a defendant Personal References List three (3) personal references (cannot be relatives, former employers, fellow employees, or school teachers), more than 25 years of age, who are householders or property owners, business or professional men or women, including your family physician, if you have one in good standing in the community, and who have known you well during the past three (3) years: Reference 1 Name * Reference 1 Years Known * Reference 1 Address (no P.O. Boxes) * Reference 1 Address (no P.O. Boxes) Reference 1 Address (no P.O. Boxes) Reference 1 Address (no P.O. Boxes) Reference 1 Address (no P.O. Boxes) Reference 1 Address (no P.O. Boxes) Reference 1 Address (no P.O. Boxes) Reference 1 Business or Occupation * Reference 1 Phone Number(s) * Reference 2 Name * Reference 2 Years Known * Reference 2 Address (no P.O. Boxes) * Reference 2 Address (no P.O. Boxes) Reference 2 Address (no P.O. Boxes) Reference 2 Address (no P.O. Boxes) Reference 2 Address (no P.O. Boxes) Reference 2 Address (no P.O. Boxes) Reference 2 Address (no P.O. Boxes) Reference 2 Business or Occupation * Reference 2 Phone Number(s) Reference 3 Name * Reference 3 Years Known * Reference 3 Address (no P.O. Boxes) * Reference 3 Address (no P.O. Boxes) Reference 3 Address (no P.O. Boxes) Reference 3 Address (no P.O. Boxes) Reference 3 Address (no P.O. Boxes) Reference 3 Address (no P.O. Boxes) Reference 3 Address (no P.O. Boxes) Reference 3 Business or Occupation * Reference 3 Phone Numbers * Family Father First Name Father Middle Name Father Last Name Father Address Father Address Father Address Father Address Father Address Father Address Father Address Father Occupation Mother First Name Mother Middle Name Mother Last Name Mother Address Mother Address Mother Address Mother Address Mother Address Mother Address Mother Address Mother Occupation Training/Skills Do you have any special training or skills? If so, please list Alcohol and Drug Use To what extent do you use intoxicating liquors? * Have you ever used marijuana? * Yes No Last Time Used How Often? Do you extensively use narcotics or drugs? * Yes No Are you taking any prescription drugs? * Yes No list the drugs and reason for taking them Other Why do you want to be a member of the Nitro Fire Department? * Are you now, or have you ever been, associated with other individuals who advocate the overthrow of our constitutional form of government, or who have adopted a policy of advocating or approving the commission of acts of force or violence to deny other persons their rights under the Constitution of the United States or who to alter the form of government of the United States by unconstitutional means? * Yes No If Yes, Explain Signature I HEREBY CERTIFY THAT THERE ARE NO WILLFUL MISREPRESENTATIONS IN, OR FALSIFICATIONS OF, THE ABOVE STATEMENTS AND ANSWER TO QUESTIONS. Type Full Legal Name * Date * Required Attachments Allowed File Types: JPEG (.jpg or .jpeg), PNG (.png), GIF (.gif), PDF (.pdf) Drivers License * Drop a file here or click to upload Choose File Maximum file size: 2.1MB Social Security Card * Drop a file here or click to upload Choose File Maximum file size: 2.1MB HS Diploma or GED * Drop a file here or click to upload Choose File Maximum file size: 2.1MB Birth Certificate * Drop a file here or click to upload Choose File Maximum file size: 2.1MB Captcha Submit If you are human, leave this field blank.