| Type of Membership:
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Name:
First, Middle, Last
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Address:
Street, City, State, Zip Code
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| SSN:
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| Date of Birth:
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| Age:
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| Driver’s License Number:
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| Driver’s License State:
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| Driver's License Class:
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| Occupation:
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| Home Telephone Number:
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| Name of Employer:
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| Employer Address:
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| Employer Telephone Number:
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| Location of Residence:
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| Distance from Firehouse:
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| Person to notify in case of an Emergency |
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| Emergency Contact Name:
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| Emergency Contact Telephone Number:
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| Emergency Contact Address:
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| Emergency Contact Relation:
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| Please list at least 2 references, not related by blood, adoption, or marriage that you have known for at least 1 year. Only 1 reference can be a member of the Seventh District Volunteer Fire Department, Inc. |
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| Reference #1 Name:
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| Reference #1 Address:
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| Reference #1 Home Phone:
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| Reference #1 Work Phone:
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| Reference #2 Name:
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| Reference #2 Address:
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| Reference #2 Home Phone:
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| Reference #2 Work Phone:
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| Reference #3 Name:
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| Reference #3 Address:
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| Reference #3 Home Phone:
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| Reference #3 Work Phone:
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| Do you have any firefighting experience? If so, provide any fire departments or rescue squads you have been affiliated with and provide copies of training records and/or a MFRI transcript. |
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Department Information:
Department Name, Phone Number, Address, Officer
- Please list all previous departments
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| Training Records:
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| Have you ever been convicted of any offense other than a minor traffic violation?:
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| If you ever been convicted of any offense please explain:
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| Do you have any known physical or permanent disabilities, which may hinder your ability to take part in firefighting activities?:
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| If you have answered yes above, please explain:
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| I certify that all the statements made on this application are true, complete, and correct to the best of my knowledge and are made in good faith. If accepted for membership I agree to abide by all rules and regulations of the Seventh District VFD |
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| Electronic Signature of applicant:
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| Date Submitted:
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04/29/2024 0130 |
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| If you are under 18 years of age, the signature of a parent or guardian is required. |
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