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Join The Community Fire Company!

We are looking for volunteers!

Join and be a part of the fire company

Submit Your Application!

Application For Membership

Personal & Contact Information

First Name *

Middle Name

Last Name *

Type of Membership *

Date of Birth *

Address *

Address

Street Address 1

Street Address 2

City

State/Province

Zip/Postal

Home Phone

Cell Phone

Driver Information

Drivers License #

State Issued

Expiration

Have you ever been convicted of any offense other than a minor traffic violation? *

Yes

If yes, please explain

Emergency Contact Information

Name of Emergency Contact *

Relationship *

Phone

Address of Emergency Contact *

Address of Emergency Contact

Street Address 1

Street Address 2

City

State/Province

Zip/Postal

Employment Information

Current Employer

Current Employer Address

Street Address 1

Street Address 2

City

State/Province

Zip/Postal

Supervisor

Supervisor Phone #

Previous Membership & Experience

Do you have any physical impairment that may interfere with your performance with CVFC? *

Yes

If yes please explain

Have you ever applied for membership with CVFC? *

Yes

If yes give aprox. Date

Have you ever been a member of any Fire/Rescue company? *

Yes

If yes give aprox. date, department name, phone number & chief's name

Attach Certificates

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List any certifications (Fire & EMS) Attach a copy of each to application

List Three (3) persons not related to you for references

Reference Name *

Phone *

Address

Street Address 1

Street Address 2

City

State/Province

Zip/Postal

Reference Name *

Phone *

Address

Street Address 1

Street Address 2

City

State/Province

Zip/Postal

Reference Name *

Phone *

Address

Street Address 1

Street Address 2

City

State/Province

Zip/Postal

PLEASE READ AND SIGN

I herby authorize Community Volunteer Fire Company Inc. of District 12, and its membership committee to investigate the statements made of this application. I will abide by the rules, regulations & by-laws set forth by Community Volunteer Fire Company Inc. of District 12. I have enclosed Five ($5.00) dollars to cover my membership dues and have filled out the attached LOSAP application.

Print Name *

Applicant Signature *

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Parent/Guardian Signature

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Date *

Date

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