Application Form

Membership Application Form

Please fill in the form below.
Full Name

PrefixFirst NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
E-mail
Drivers License Class
Expiry Date
Restrictions
Employer
Occupation
Employers Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Education Completed (Name of Institute)
Level Completed
Emergency Contact Name
Emergency Contact Phone Number

Area CodePhone Number
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a current member of the Provincial Emergency Program?
Name of Reference
Phone Number

Area CodePhone Number
Name of Reference 2
Phone Number

Area CodePhone Number
List any and all emergency service and work experience
Please list all applicable training, skills, and specialized training you have, including level of training
In your own words, please explain why you are interested in becoming a volunteer member of the Prince George Regional Highway Rescue
Prince George Regional Highway Rescue is a volunteer, non-profit organization.

As a member of the Dept. you must be willing to:
1. Abide by Constitution, Bylaws and Policies of the Dept.
2. Volunteer your time to attend training, provide shift coverage, perform rescue operations and assist with fundraising and other functions of the Dept.
3. Take training as provided to the prescribed levels
I hereby certify that all the above information is true to the best of my knowledge:
Full Name
Date

MonthDayYear
The Chief will consider your application for membership. (You will be advised if you have been accepted.)

To be Completed by the Chief:
Approved
Name of Chief
Date

MonthDayYear
Additional comments
Should be Empty:

Membership Application Form