MVFC - Application for Membership
Name
*
First Name
Last Name
Responder Type
Active Responder
Non Responder
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at the address above?
*
Phone #
*
Please enter a valid phone number.
Email Address
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Drivers license information
State
*
Number
*
Class
*
Education information
High school:
College:
Technical school:
Employment
Name of Employer:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone #:
Please enter a valid phone number.
Supervisor:
References: Name three persons, not related to you that we may contact. You must have known these people for at least six months.
#1 Reference - Name
*
First Name
Last Name
#1 Reference - Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
#1 Reference - Phone Number
*
Please enter a valid phone number.
#2 Reference - Name
*
First Name
Last Name
#2 Reference - Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
#2 Reference - Phone Number
*
Please enter a valid phone number.
#3 Reference - Name
*
First Name
Last Name
#3 Reference - Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
#3 Reference - Phone Number
*
Please enter a valid phone number.
#1 - Name
*
First Name
Last Name
#1 - Signature
*
#2 - Name
*
First Name
Last Name
#2 - Signature
*
Previous Fire/Rescue Organizations
#1 - Name
First Name
Last Name
#1 - Phone Number
Please enter a valid phone number.
#2 - Name
First Name
Last Name
#2 - Phone Number
Please enter a valid phone number.
Fire/Rescue Training: please list with expiration dates. Please also bring copies of your training records
*
If you are applying for active status, you will be required to pass a physical examination and drug testing. Do you have any impairment that would interfere with your abilities for perform in emergency situations?
*
Yes
No
Have you ever been convicted of any crimes or traffic violations, if yes please explain
*
Yes
No
Finally why would you like to join the Middletown Vol. Fire Co.?
*
Please Read and Sign I authorize a background investigation and validation of all statements contained in this application. I understand that any misrepresentation or omission of any information requested is cause for dismissal, before or after my membership is accepted. I also understand that my membership is for an indefinite time period. If during that time I obtain any company or county property, I will return the property when no longer needed or at the termination of my membership.
A processing fee will be collected at the time of the interview that is the responsibility of the applicant.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Name
*
First Name
Last Name
Parental Permission Slip for Membership
This form is to be signed by the parent or legal guardian of the applicant if under the age of 18years old, prior to acceptance of membership.
I give permission for my Son/Daughter to become a member of theMiddletown Vol. Fire Co. In the case of an accident or injury while performing duties related to Fire/Rescue activities; I will not hold the Middletown Vol. Fire Co. Responsible. I may at any time revoke my permission by addressing a letter to the president of the company. After such letter is received my child will be suspended until permission is resubmitted or he/she reaches their 18th birthday. I have authority of my Son/Daughter while he/she is a member until the age of 18.
First Name
Last Name
Name of applicant
First Name
Last Name
Applicant’s signature
Parent or Guardian signature
Submit
Should be Empty: