PERSONAL
Last Name
Date
First Name
E-mail Address
MI
Street Address
City, State, Zip
How long have you lived at this address?
Home Phone
Business Phone
Sex (M/F)
Social Security Number
Where are you currently employed?
If you were in the Armed Forces, when were you discharged? Month/Year
Are you over 18 years of age?
Date of Birth
Have you ever been convicted of a traffic violation, misdemeanor, or a felony
If Yes, indicate the date and nature of the charge, police agency, court and disposition.
EXPERIENCE
Have you ever filed an application with Dumfries - Triangle Volunteer Fire Department?
If so, when?
Have you ever been denied membership to a fire and/or rescue squad?
If so, please give details.
Have you ever been discharged for misconduct or unsatisfactory service or asked to resign from a fire and/or rescue department?
If so, please give details.
List any fire fighting and/or emergency medical certifications that are current. Please attach copies of certifications.
Certifications
State
EDUCATION
High School attended
Location (City/State)
Did you graduate or receive a GED?
Date graduated, or received GED
College or University
Location (City/State)
Dates attended
Major or Degree awarded
MEDICAL HISTORY
Have you ever...
had an operation?
Select Answer
No
Yes
been seriously injured?
Select Answer
No
Yes
been refused employment for reasons of health?
Select Answer
No
Yes
been forced to resign from a job or volunteer position for health reasons?
Select Answer
No
Yes
fractured any bones or dislocated any joints?
Select Answer
No
Yes
been refused life insurance?
Select Answer
No
Yes
been diagnosed with an illness caused by your job or volunteer position?
Select Answer
No
Yes
injured your back?
Select Answer
No
Yes
suffered from lung problems?
Select Answer
No
Yes
suffered from heart problems?
Select Answer
No
Yes
suffered from swelling of the legs or ankles?
Select Answer
No
Yes
suffered from fainting spells or dizziness?
Select Answer
No
Yes
suffered from frequent headaches?
Select Answer
No
Yes
been hospitalized or on medication for mental illness?
Select Answer
No
Yes
Do/are you...
currently wearing glasses?
Select Answer
No
Yes
using a hearing aid?
Select Answer
No
Yes
on any medications?
Select Answer
No
Yes
If you answered yes to any of the above, please provide more information.
REFERENCES
Please list 3 references, not related to you by blood, adoption, or marriage, that you have known for at least one year. References should not be members of 3/17 fire.
NAME
ADDRESS
WORK PHONE #
HOME PHONE #
Please provide any previous fire departments or rescue squads that you have been a member of:
DEPARTMENT
ADDRESS
DUTY OFFICER
PHONE NUMBER
The following information must be provided by or will be obtained on behalf of all applicants:
1. Criminal History Check
2. CCH (State) Criminal Check
3. DMV Record
4. Report Card (If still in High School)
Drivers License #
State Issued
ACKNOWLEDGEMENT
By signing below, I signify that I have applied for the membership to the Dumfries-Triangle Volunteer Department; that I have answered all questions truthfully and to the best of my knowledge; and that I fully understand that any intentional false statement may be grounds for dismissal from the department. Furthermore, I hereby grant to the Dumfries-Triangle Volunteer Fire Department permission to contact my employer, references, and any other persons or agencies who may have knowledge of me, my skills and my experience as may be deemed necessary. I also understand that I may be required to undergo a mandatory physical, performed by the Department's doctor, at the Department's expense in order to be considered for Operational Membership.
Please type your signature here:
Applying for:
Who may we thank for referring you?
