Dumfries Triangle Volunteer Fire Department
Dumfries Triangle Volunteer Fire Department
Can You Fill These Boots?

Join Our Team!

Use the form below to apply for membership to the Dumfries-Triangle Volunteer Fire Department. After completing this form, a representative of the membership committee will contact you. In the meantime, feel free to come down and visit the station.

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)
       
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?
  been seriously injured?
  been refused employment for reasons of health?
  been forced to resign from a job or volunteer position for health reasons?
  fractured any bones or dislocated any joints?
  been refused life insurance?
  been diagnosed with an illness caused by your job or volunteer position?
  injured your back?
  suffered from lung problems?
  suffered from heart problems?
  suffered from swelling of the legs or ankles?
  suffered from fainting spells or dizziness?
  suffered from frequent headaches?
  been hospitalized or on medication for mental illness?
       
Do/are you... currently wearing glasses?
  using a hearing aid?
  on any medications?
       
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?    


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Dumfries Triangle
Volunteer Fire Department

P.O. Box 340
Triangle, VA 22172

Emergency Dial 911
Station 3: (703) 221-4242
Station 17: (703) 680-3517
E-mail: info@dumfriesfire.com
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