Lake Jackson Volunteer Fire & Rescue Membership Application

Lake Jackson Volunteer Fire & Rescue Membership Application
Personal Information
Date of Application

MonthDayYear
Date
Name*

First NameMiddle NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Gender*
Age
Age Days
Social Security #
What are you interested in doing at Lake Jackson Volunteer Fire & Rescue?*
Are you legally able to work in the United States?*
How did you hear about Lake Jackson Volunteer Fire & Rescue?
Please explain why you are interested in joining Lake Jackson Volunteer Fire & Rescue.
References

Please list 3 references, that you have known for over 3 years, that we may contact.
Name of Reference #1

First NameLast Name
Phone Number of Reference #1
Please enter a valid phone number.
How do you know Reference #1?
Name of Reference #2

First NameLast Name
Phone Number
Please enter a valid phone number.
How do you know Reference #2?
Name of Reference #3

First NameLast Name
Phone Number
Please enter a valid phone number.
How do you know Reference #3?
Employment

Please list your current (or most recent employer)
Employer Name
Job Title
Start Date

MonthDayYear
Date
End Date (If Applicable)

MonthDayYear
Date
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Experience

Please list any previous Fire & Rescue experience. Lack of experience will not negatively impact your application process.
Have you previously filed an application with the Lake Jackson Volunteer Fire and Rescue Department?*

YesNo
If yes, when?

MonthDayYear
Date
Have you ever been denied membership to any Fire and/or Rescue department or other volunteer organization?*

YesNo
If yes, please explain
Have you ever been discharged or asked to resign from any Fire and Rescue dept. or other volunteer organization?*

YesNo
If yes, please explain
Do you currently have a Virginia or National EMT Certification?*

YesNo
Are you currently certified as a Firefighter?*

YesNo
Please list any existing certifications and their expiration dates, if applicable.
Please list any additional experience you feel may benefit you at Lake Jackson Volunteer Fire & Rescue.
Education

Please list your highest level of education.
Educational Institution*
Highest Education Level*
Graduation (or Anticipated) Date*

MonthDayYear
Date
Major/Focus of Study
Criminal History
Acceptance in to membership at the Lake Jackson Volunteer Fire & Rescue department is contingent on successfully passing a criminal background check. If you are interested in becoming a Firefighter or EMT, your driving record will also be requested from the DMV. After your application is received, a member of Lake Jackson Volunteer Fire & Rescue will reach out to discuss fingerprinting requirements and collect any additional details needed to conduct the background check.
Have you ever been convicted of a moving traffic violation, misdemeanor, or felony?*

YesNo
If yes, Please explain
Are you currently under any pending indictments or charges?*

YesNo
If yes, Please explain
Have you ever engaged in the use of illegal substances or been addicted to controlled substances?*

YesNo
If yes, Please explain
Do you understand that by joining the Lake Jackson Volunteer Fire and Rescue Department that you are agreeing to voluntarily submit to initial, random, and for cause drug and/or alcohol screening at the discretion of the Department?*

YesNo
Health Information
Do you acknowledge that you will be required to undergo annual physicals, at no cost to you? Failure to obtain medical clearance will limit your ability to provide emergency services.*

YesNo
Emergency Contact Information

Please identify an emergency contact
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relation*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signatures
I hereby certify that the information contained herein is true, accurate, and complete to the best of my knowledge. I understand that should any information provided, or by omission, prove false, misleading, or erroneous, my application may be delayed or rejected. I further certify that any information given under false pretense could lead to my immediate dismissal from the Lake Jackson Volunteer Fire and Rescue Department, should I be accepted in to membership.*

Clear
The below section must be completed for all applicants under the age of 18.
I hereby certify that I am the Parent or Legal Guardian of the Applicant and that the above named individual has my permission to apply for membership and participate in Fire and Rescue activities with the Lake Jackson Volunteer Fire and Rescue Departmental though he or she is under the age of 18 at the time.

Clear
Name of Parent/Guardian

First NameLast Name
Phone Number
Please enter a valid phone number.
Should be Empty:

Lake Jackson Volunteer Fire & Rescue Membership Application

Personal Information

References

Employment

Previous Experience

Education

Criminal History

Health Information

Emergency Contact Information

Signatures