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July 30, 2010

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Fire Fighter Intake Form

Please fill out the information requested below and a representative will contact you.

Name:


Address (City, State, Zip):


Email:


Home Phone Number:


Work Phone Number:


Social Security Number:


Date Of Birth:


Military Background?
Yes
No

Have You Had A Trucking, Construction or Factory Job?
Yes
No

Do You Or Have You Shot Guns?
Yes
No

If So, Did You Or Do You Use Hearing Protection?
Yes
No

Do You Have Any Significant Medical Condition Affecting Your Hearing?
Yes
No

Have you been injured or involved in an accident within the last 2 years?
Yes
No

Have you had your breathing checked within the last 2 years?
Yes
No

Have you ever smoked cigarettes?
Yes
No

If yes, age at which you started smoking:


Amount smoked daily:


Age at which you stopped smoking:


Name Of Fire Department?


Date First Employed As A Fire Fighter:


Current Rank:


Date Of Retirement (If Applicable):


Vehicles Assigned To (Include Years):


Positions Held:
Tiller
Driver/Passenger Jumpseat
Engineer
Officer
manufacturers Of Sirens
Models
Mechanical
Electronic

Open Cabs?
Yes
No

Date Of First Hearing Loss Medical Examination:


Date Of Any Workers' Compensation Or Disability Claim Filed For Hearing Loss:


Treating Doctors (For Hearing)

Name:


Address (City, State, Zip):


Phone Number:


Specialty:

First Name: Last Name:
Phone:
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Sending this message does not create an attorney-client relationship, which can be done only after personal consultation and with a written retainer agreement.
Office Locations
Jersey City

660 Newark Avenue
Jersey City, NJ 07306
Phone: (201) 656-8500
Toll: 1-(866)-333-3529
info@bagoliefriedman.com
Clifton Offices

790 Bloomfield Avenue
Clifton, NJ 07012
Phone: (973) 546-5414

157 Ackerman Avenue
Clifton, NJ 07011
Phone: (973) 546-5414
Florida Office

3900 Hollywood Blvd.
Hollywood, FL 33021
Phone: (954) 966-2322
Fax: (954) 927-0337
© 2010 - Bagolie Friedman, LLC
Personal Injury Attorneys serving clients in the State of New Jersey. All Rights Reserved.

Disclaimer: The New Jersey personal injury, wrongful death, worker's compensation, medical malpractice, nursing home abuse, product liability, environmental litigation, social security law, railroad / FELA, firefighter hearing loss, Asbestos / Mesothelioma, Lead Paint Poisoning and/or other legal information offered herein by Bagolie Friedman, LLC - Jersey City and Clifton New Jersey and Hollywood Florida Personal Injury Attorneys is not formal legal advice nor the formation of an attorney client relationship. Our law firm is licensed to practice law in New Jersey, New York and Florida. Nationwide and international coverage through associated counsel.