Name:                                 Date:                                          
Address:   
City:       State:          Zip:
Social Security Number:                     Date Of Birth:
Home Phone:                                Work Phone:                Cell Phone:       
Which type of Membership are you applying for?    Fire Membership    Rescue Membership    Fire & Rescue Membership     Support Membership
*Membership Requires 8 Hours per Week*
Are You Currently Employed:    Yes    No
Current or Most Recent Employer:
Supervisor's Name:    Phone:

Education (List Highest Grade Completed):    Name of School:
List Any Experience or Certifications (With the Expiration Dates) You May Have at This Time:


Are you currently a member, or have you ever been a member, of any other Fire Department or Rescue Squad? Yes    No
If Yes, List Name(s) of the Agency(s):
Have you ever been convicted of any Law Violations (Excluding Moving Violations): Yes    No
If yes, please explain:
Please List 3 References (Not Family Members or Members of this Department):
                    NAME
Reference 1:    Relation:    Phone Number:
Reference 2:    Relation:    Phone Number:
Reference 3:    Relation:    Phone Number:

Do you have any Medical Condition(s) that would hinder or compromise your ability to provide or participate in any Fire and/or Rescue Duties? Yes    No
If yes, please explain:
Name of the Nearest Relative to notify in case of an Emergency:
Name:        Phone:

If you are under the age of 18, parent's or legal guardian's signature will be required for this application to be accepted for membership.

The Churchville Volunteer Fire Department and Rescue Squad does not discriminate by age, sex, religion or national origin.  I understand that before I am assigned to a volunteer position with the Churchville Volunteer Fire Department and Rescue Squad, that a standard background investigation will be conducted.  Upon having an interview and before being accepted as a member you will have to sign a form authorizing us to obtain the said background check.  By typing your full name below and dating it, you are submitting this application with your electronic signature.  I hereby state that by submitting this application that the above information is true and correct.