Nokesville Volunteer Fire and Rescue Department, Inc.

Application for Active Membership

Personal Information
*Full Name:
*Preferred Name:
*Address:
*How long at this address?:
Previous Address:
*Home Phone:
Work Phone:
Cell Phone:
Email Address:
*Birth Date:
*Place of Birth:
*Age:
*Social Security Number:
Race:
Sex:
Driver's License Number:
*State:
Marital Status:
Number of Children:
Do you have any medical or physical condition(s) that would interfere or affect your ability to perform the duties
*required of a firefighter and/or EMS provider (ie, pulling, lifting, carrying, dragging)?:
*Are you able to lift seventy (70) pounds?:
*Are you willing to take a physical/medical examination including a drug-screening test?::
*Area of Interest:
*Are you a citizen of the United States?:
Have you ever been convicted of a traffic violation (not including parking tickets), a misdemeanor, or a felony?
(If yes, indicate the date and nature of the charge, police agency, court and disposition):
Are you currently under any pending indictment or charge?
If yes, indicate the date and nature of the charge, police agency, court and disposition:
Have you ever served in the armed forces?:
Date of Discharge:
Type of Discharge:
Employment Information
Current Occupation:
Employer Name:
Address:
Phone:
Supervisor:
How Long Employed There?:
Are you Legally Entitled to Work in the United States?:
Prior Employment Information
Please Provide 5 Years of Work History (Name, City, State, Phone & Dates Employed):
Education
Name of High School?:
High School Address?:
Did you graduate?:
Please list any additional education:
Community/School Organizations
Please list any Clubs, Societies, or Organizations that you Currently Belong to
(Please Include Group Leader Name and Telephone Number):
Prior Fire/Rescue Experience
Have You Had Previous Fire/Rescue Experience?:
If Yes, Department Name:
Address:
Phone:
Reason for Leaving:
Please List All Fire/EMS Certifications Received
(Including State of Issuance & Date of Issuance) and please attach copies of certifications:
References
Please provide three (3) references (Persons NOT related to you). All must have known you for three (3) years or more.
Name:
Address:
Home Phone:
Work Phone:
Cell Phone:
How are you Acquainted?:

Name:
Address:
Home Phone:
Work Phone:
Cell Phone:
How Are You Acquainted?:

Name:
Address:
Home Phone:
Work Phone:
Cell Phone:
How Are You Acquainted?:
Driving Record
Upon receipt of your application, we will order your Driving Record from the Department of Motor Vehicles. This will be done at no charge to you.
Criminal Record
Upon receipt of your application, we are required by law to order a Virginia State Police “Criminal History and Sex Offender & Crimes Against Minors Report”. This will be done at no charge to you. If you are voted in for membership, you will not be able to respond to any emergency calls until this report is obtained. It will take approximately 15 days from the date we place the order. This report is kept confidential.
General Information
Junior member applicants MUST submit copy of the most recent report card with application. In one paragraph or more, describe why you desire to become a member of the Nokesville Volunteer Fire & Rescue Department
Why?:
How did you hear about us?:

I hereby authorize the Nokesville Volunteer Fire and Rescue Department Inc. to perform a complete background investigation on me, including my driving and criminal record. I, the undersigned, certify that the information contained herein is true and complete to the best of my knowledge. I understand that should any statement I have made prove false, misleading, erroneous, it may result in the rejecting of my application or in my discharge from the Nokesville Volunteer Fire and Rescue Department, Inc. I also agree to abide by and uphold the rules, regulations, and by-laws of the Nokesville Volunteer Fire and Rescue Department, Inc. Upon resignation or termination of my membership, I agree to return all items issued by the Nokesville Volunteer Fire and Rescue Department, Inc., including but not limited to pager/radio, protective gear, uniforms and any other items entrusted to me.