Clear Brook Volunteer Fire & Rescue, Inc.

Online Membership Application

Name of Applicant   Birth date

Home Address   Sex  Male Female

Home Phone Social Security Number

Employer's Name

Employer's Address

Work Phone Occupation Working Hours

Do you hold a VA driver's license ? Yes No What Type Basic CDL Learners Expiration

Any Military Service No Army Navy Air Force Marines National Guard   Type of Discharge

Would you submit to a voluntary drug test Yes No

Have you ever been convicted of a felony or criminal act No Yes

If yes Explain

Who should be notified in case of an emergency

Phone Number Home Work Other

Have you ever been a member of another Fire & Rescue Company No Yes

If so are you still a member No Yes Name of Company

Date Joined Date Left

List any Previous experience in Fire & Rescue Work (Please attach copies of any certifications)

Name of Company Date Joined Date Left

Name of Company Date Joined Date Left

Name of Company Date Joined Date Left

Do you have any previous training in Fire & Rescue Yes No

Do you hold any NFPA Certifications No Yes   What Level None Instructor 1 Instructor 2 Instructor 3 Instructor 4 Officer 1 Officer 2 Firefighter 1 Firefighter 2

Do you hold any EMS Certifications No Yes   What Level None First Responder EMT-Basic EMT-Optional EMT-Enhanced EMT-Intermediate EMT-Paramedic

Last Year attended school Name of School

Please provide 3 personal References below

Name                                                Address                                                        Phone

1                

2                

3             

I voluntarily agree to be governed by the By-laws of Clear Brook Volunteer Fire & Rescue, Inc. and pledge my support for its future success. I understand any false information on this application will make it invalid. I also understand a DMV Driver's Record must be presented to the Membership Committee with this application. Dues of $ 5.00 for membership are due upon election into the company and every year thereafter by the Annual Membership Meeting in October. All members are subject to a 6 month probation period. With my signature below, I give permission for the investigation of all information provided on this application.

Applicants Signature _______________________________________________________

If applicant is under 18 years of age, you must have Parental Consent.

Signature of Parent or Legal Guardian _________________________________________

Today's Date  

Sponsored By