Membership Application - Essex Volunteer Fire Company

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Membership Application

Indicates Required Field

Membership Type:

Personal Information

Preffix:
First Name:
Middle Name:
Last Name:
Suffix:
Street Address :
City:
State:
Zip Code:
Are You An American Citizen:		Yes No
Date of birth:
Are you over the age of 18:		Yes No
Social Security Number:
Sex:		Male Female
Cell phone:
Home phone:
Email Address:

Education

High School Attended:
Current Grade or Last Grade Attended:
Did You Graduate:		Yes No
Drivers License Number:
State and Class:

Military Service

Have You Served In The Military:		Yes No
Are you currently serving in the national gaurd or reserves:		Yes No
Branch of service:
Date of discharge:
Type of discharge:

Employment Information

Are you currently employed :		Yes No
Employer Name:
Immediate Supervisor :
Employer phone:
Employer Address :
May we contact your employer :		Yes No

Emergency Services Experience

Do you currently or have you ever volunteered in Emergency Services :		Yes No
If you answered yes to the previous question where:
Current certifications :		FFI FFII FOI FOII RESCUE TECH HAZMAT AWARENESS HAZMAT CORE COMP HAZMAT OPS HAZMAT TECH BCoFD BBP EMR EMT-B EMT-I CRT EMT-P
Any Other Certifications :

References

List atleast three professional references that are not related to you. Be sure to include Name, Address & Phone Number for each reference :

Verification

Do you consent to a background check :		Yes No
Do you acknowledge that you will be required to submit to a pre-acceptance toxicology screening conducted by a third party agency :		Yes No
Signature :
If under the age of 18 parent/guardian signature :
Date:		04/25/2024 2020

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www.FirehouseSolutions.com	Essex Volunteer Fire Company 1449 Sussex Road Essex, MD 21221	Emergency Dial 911 Phone: (410) 887-0329 E-mail: info@essexvfc.org