Vigilant Hose Company Membership Application

Membership Application

Vigilant Hose Company
Applicant Information
Membership Applying For
Operational Position Applying For
Applicant Name

First NameLast Name
Middle Initial
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Driver’s License Number
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Doctor’s Name

First NameLast Name
Doctor’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Education
Highest level of education completed
High School / College name
Year completed (or currently enrolled)
Employment History
Current Employer
Current Position Held
Current Employer Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current Employer Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Current Employment Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Employment End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Previous Employer
Previous Position Held
Previous Employer Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Previous Employment Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Previous Employment End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
References
Reference 1 Name

First NameLast Name
Reference 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference 1 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reference 2 Name

First NameLast Name
Reference 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reference 3 Name

First NameLast Name
Reference 3 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference 3 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Membership and Service History
Prior Vigilant Hose membership?
Prior Vigilant Hose membership date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Served in another Fire/EMS Department?
Other Fire/EMS department service date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other Fire/EMS department name
Other Fire/EMS department address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Other Fire/EMS department telephone
Please enter a valid phone number.Format: (000) 000-0000.
Other Fire/EMS department date of service

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of current Chief

First NameLast Name
Current Chief’s Recommendation (Must be submitted at time of interview with official letterhead)
Authorized fire/rescue vehicle driven (a)
Authorized fire/rescue vehicle driven (b)
Authorized fire/rescue vehicle driven (c)
Authorized fire/rescue vehicle driven (d)
Highest rank held
Fire/Rescue/EMS training (a)
List all Fire/Rescue/EMS training you have completed
Fire/Rescue/EMS training (b)
List all Fire/Rescue/EMS training you have completed
Fire/Rescue/EMS training (c)
List all Fire/Rescue/EMS training you have completed
Reason for wanting to become a member
Declarations and Signature
Driver’s license ever suspended or revoked?
Driver’s license suspension details
Have you ever been convicted of a criminal offense?
If yes, please provide details
Applicant's Signature
Application Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Membership Application

Applicant Information

Emergency Contact

Education

Employment History

References

Membership and Service History

Declarations and Signature