Application for Active Membership
If you would like to apply for active membership with the Nokesville Volunteer Fire and Rescue Department, please complete the following form. The application takes approximately 10-15 minutes to complete.
Name:
*
First Name
Middle Initial
Last Name
Current Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at this address?
*
Please indicate months or years in your response.
Phone Number:
*
Please enter a valid phone number.
Email Address:
*
example@example.com
Birth Date:
*
-
Month
-
Day
Year
Date
Social Security Number:
*
If you do not have an SSN, enter "N/A".
Driver's License Number:
*
If you do not possess a valid driver's license, enter "N/A".
Which state issued your driver's license?
*
If you do not possess a valid driver's license, enter "N/A".
Are you legally permitted to work in the United States?
*
Please Select
Yes
No
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Personal Information
Please indicate your area of interest:
*
Fire
EMS
Fire and EMS
Business member
Do you have any medical or physical conditions that would interfere with or affect your ability to perform the duties required of a firefighter or EMS provider (e.g., pulling, lifting, carrying, and dragging)? If so, please explain.
*
Are you able to lift 70 pounds?
*
Please Select
Yes
No
Unsure
Are you willing to take a physical/medical examination, to include a drug screening test?
*
Please Select
Yes
No
Have you ever been convicted of a traffic violation (not including parking tickets), a misdemeanor, or a felony? If yes, explain in the field below. For each conviction, provide the date, 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, the police agency, and court.
*
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Employment Information
Employer Name:
*
Employer Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Phone Number
*
Please enter a valid phone number.
Name of Supervisor:
*
How long have you worked for this employer?
*
Prior Fire & Rescue Experience
Do you have prior fire/rescue experience?
*
Please Select
Yes
No
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Prior Fire/Rescue Experience
Department Name:
Department Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Department Phone Number:
Please enter a valid phone number.
Please list all current fire and EMS certifications you hold, including the state and date of issuance for each. Copies of all of your certifications will be required during the application process.
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References
Please provide 2-3 character references.
Reference #1
*
Reference #2
*
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Acknowledgements & Authorizations
Read the following statements carefully. Once you have finished reading, click the check box to indicate agreement to the terms.
Application Submission
Complete the authentication question below, and then click "Submit" to complete your application.
Please verify that you are human
*
Submit
Should be Empty: