Department General Information Chief of Department: Tony Averbuch Telephone: 248.626.9862 Fax: 248.626.6111 Postal Address: 32707 Franklin Rd., Franklin, MI 48025

Annual Medical Statement of Personnel NOTE: This form is designed to provide the individual in charge of all personnel a complete history of physical status as of the date indicated without the need for expensive physical examinations. It is recommended that the form be completed on an annual basis by all

www.fbfd.com. Please attach copies of all relevant certificate and licensure to your application. Title: Elegant Letter Author: Tony Averbuch Created Date:

Franklin-Bingham Fire Department OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Can you read (circle one): Yes/No Your employer must allow you to answer this questionnaire at a time and place that is convenient

Franklin-Bingham Fire Department Candidate Background Investigation Authorization & Release Agreement Candidate’s Full Name_____ Date of Birth_____ Social Security Number_____