Membership Application

Complete the form below to apply for membership with the Fredon Volunteer Fire Company. Fields marked with an asterisk (*) are required.

Personal Information

Full Name *

Address *

Home Phone #

Mobile Phone #

Date of Birth *

Address (if different in last two years)

Social Security #

Driver's License #

References

Please provide three references (other than relatives or roommates) who can attest to your character or verify any statement made within this application.

Reference 1

Name

Phone #

Reference 2

Name

Phone #

Reference 3

Name

Phone #

Education / Employment History

List your last two employers.

Employer 1

Name

Address

Business Phone #

Employer 2

Name

Address

Business Phone #

High School or College Experience

Driving / Criminal / Discipline History

In the past 5 years, have you received any moving violations/tickets, been involved in any auto-related accidents, or had your license suspended?

No Yes

Have you ever been convicted of a crime other than a motor vehicle offense?

No Yes

Have you ever been disciplined, suspended, removed, or dismissed from a Fire, Rescue, and/or EMS Service?

No Yes

Medical History

Physician's Name

Phone

Do you have allergies or outstanding medical, mental, emotional, or physical limitations that affect your ability to perform the tasks appointed to you?

No Yes

Some tasks of the Fredon Volunteer Fire Company may involve strenuous activity. I initial here to give my consent to a doctor's physical examination, provided by the Fredon Volunteer Fire Company, at no cost to me.

Initials

Fire / Rescue / EMS Affiliations

Are you currently, or have you ever been, a member of a Fire, Rescue, and/or EMS Service?

No Yes

Company 1

Company Name

Contact

Phone #

Company 2

Company Name

Contact

Phone #

Do you have any training/certifications related to Fire, Rescue, and/or EMS?

No Yes

List training and graduation dates. Attach additional pages if needed. Proof of completion must be provided to complete your training file.

Criminal / Motor Vehicle Background Search Agreement

I understand as part of the membership review process and probationary period of the Fredon Volunteer Fire Company, routine criminal and motor vehicle background checks are made in order to preserve the integrity of the Company and ensure the safety and security of the lives and property entrusted to the Company. I hereby agree to have a criminal and motor vehicle background search performed by an official representative of the Fredon Volunteer Fire Company. I also understand that the results of these searches may be needed to complete my membership review and can affect my membership or probationary status.

Social Security #

Driver's License #

Name (print) *

Signature

Date *

Statement of Intent

I hereby state that the information I have provided in my application for membership to the Fredon Volunteer Fire Company is true and correct to the best of my knowledge. I understand that any misstatements or misrepresentations of myself or my credentials will be grounds for immediate review or dismissal by the membership committee. If accepted for membership, I agree to abide by the Constitution, Bylaws, and Guidelines set forth and promulgated by the Fredon Volunteer Fire Company.

Name (print) *

Signature

Date *

Fields marked * are required before printing will proceed cleanly.