Volunteer Application
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Are you a citizen of the United States?
*
Yes
No
Have you ever worked or volunteered for Nottoway County Emergency Squad?
*
No
Yes, please list date(s) & reason(s)
Have you ever been convicted of a felony?
*
No
Yes, please explain:
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Education
Name of High School
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
From
Date
*
To
Date
*
Did you graduate?
*
No
Yes, Degree:
College
Name of College
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
From
Date
To
Date
Did you graduate?
No
Yes, Degree:
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References
Reference Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Relationship
*
Reference Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Relationship
*
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Employment History
Most recent 3 employers -OR- back 7 years, starting with the most recent.
Employer Name
*
Supervisor Name
*
First Name
Last Name
Supervisor Email
*
example@example.com
Supervisor Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
From
Date
*
To
Date
*
Are you still working here?
*
Yes
No, Reason for leaving?
Do you need to add an additional employer?
*
Yes
No
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Employment History (Continued)
Employer Name
*
Supervisor Name
*
First Name
Last Name
Supervisor Email
*
example@example.com
Supervisor Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
From
Date
*
To
Date
*
Are you still working here?
*
Yes
No, Reason for leaving?
Do you need to add an additional employer?
*
Yes
No
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Employment History (Continued)
Employer Name
*
Supervisor Name
*
First Name
Last Name
Supervisor Email
*
example@example.com
Supervisor Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
From
Date
*
To
Date
*
Are you still working here?
*
Yes
No, Reason for leaving?
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Military Service
Have you served in the military? (previous or current)
*
Yes
No
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Military Service
Branch
*
From
Date
*
To
Date
*
Rank at Discharge? (or current rank)
*
If you were discharged, what type of discharge?
If still active, please leave blank.
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Other Information
Please list any members (volunteer or career) that you know or referred you to this organization?
*
If you do not know any current members, please list n/a.
Describe why you want to be a volunteer at Nottoway County Emergency Squad?
*
If you have ever been affiliated with any Police, Fire, EMS or other like organizations, please provide the name, address, and phone number of said organization and your current status.
*
If none, please list n/a.
If you have any certifications (CPR, EVOC, EMT, etc.) please upload them here.
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Please upload a copy of your Drivers License
*
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Certification
I certify that my answers are true and complete to the best of my knowledge. If this application leads to membership, I understand that false or misleading information in my application or interview may result in my release.
*
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