CHRISTIANBURG FIRE DEPARTMENT
APPLICATION FOR MEMBERSHIP
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Driver License Number
*
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.
Have you ever been a convicted of a felony?
*
Yes
No
If yes, please provide details.
Have you ever been convicted of a misdemeanor?
*
Yes
No
If yes, please provide details.
List two professional references
1. Reference Name
*
First Name
Last Name
1. Reference Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
2. Reference Name
*
First Name
Last Name
2. Reference Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Why do you want to join Christianburg Volunteer Fire Department?
*
Do you have any fire service experience? If so, please list below
I hereby affirm that all the information contained above is true and correct to the best of my knowledge. I understand that any false or misleading information may result in immediate termination from the department. I also authorize CVFD to conduct a background check and to contact the references listed above.
Signature
*
Today's Date
*
-
Month
-
Day
Year
Submit
Submit
Should be Empty: