Membership Application Form

Ballville Volunteer Fire Department Membership Application

To apply for membership, please complete all questions.
Date *

Month Day Year
Date
Applying for: *

Firefighter Social Member Cadet Firefighter
Applicant Information
Name *

First Name Last Name
Address *

Street Address

Apt. #

City State

Zip Code
Home Number *
Cellular Number *
E-mail *
Date of Birth *

Month Day Year
Date
Social Security # *
Height (Ft./In.) *
Weight (lbs.) *
Personal Background Information
Valid Driver License # *
Driver License Expiration Date *

Month Day Year
Date
Do you have a driving record? *

Yes No
If so, please explain
Have you ever been convicted of a misdemeanor or felony? *

Yes No
If so, please explain
Have you ever been arrested? *

Yes No
If so, please explain
Previous Experience
Have you ever been a member of any other fire department? *

Yes No
If so, please give department name, Chief's name, address and phone number, and date of membership.
Do you have any fire or medical training? *

Yes No
If yes, please be specific. Include certification number(s), if applicable.
Employment Information
Are you currently employed? *

Yes No
If yes, please state the kind of work you do, as well as the company name, address, and phone number.
If employed, what is your company's policy on you leaving work to respond to fire/medical emergencies?
May we contact your employer? *

Yes No
I hearby give permission to the Ballville Volunteer Fire Department to conduct a criminal and driving record check on me. I certify the information provided is correct and I understand falsifying this application could lead to charges against me and will revoke my membership status.

I understand I must pass a firefighter physical and drug screen in order to be considered for active membership. I am aware I must complete a required amount of training in order to be an active firefighter. I have discussed this with my family and have thier blessing to serve.

I understand that I must obtain my Volunteer Firefighter certification within the first year of my membership anniversary, and will serve a one year probationary period after the date of completion of said certification.
Signature
Signature Date *
MM/DD/YYYY
References

(No Relatives)
Reference #1 - No Relatives
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *
E-mail
Reference #2 - No Relatives
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *
E-mail
Reference #3 - No Relatives
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *
E-mail
Please note: Three complete references are required to complete this application.
________________________________________________________________

Office Ues Only
1st Reading Date:
2nd Reading Date:
3rd Reading Date:
Interview Date:
Approval / Disapproval Date:
Department Membership Coordinator
Should be Empty:

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Ballville Volunteer Fire Department Membership Application

Applicant Information

Personal Background Information

Previous Experience

Employment Information

References