| Name of
Applicant:_____________________________ |
Date of
Birth:_________________________ |
| Home
Address:______________________________________________________________________ |
| Home Ph.
#:__________________________________ |
Work Ph.
#:__________________________ |
| Employer
&
Address:_________________________________________________________________ |
| Occupation:___________________________________ |
Social
Security#:_______-_______-______ |
| Type
of Virginia Driver's
Permit:________________________________________________________ |
I am a
member or have been a member of the following fire or rescue
departments:________________
___________________________________________________________________________________ |
Describe
fire and rescue training and or
experience:_________________________________________
___________________________________________________________________________________ |
I
have the following physical
disabilities:___________________________________________________
___________________________________________________________________________________ |
Doctor's
Name and
Address:___________________________________________________________
__________________________________________________________________________________ |
If
you have ever been convicted of a felony, please describe:
|
I
hereby authorize the North Mountain Fire And Rescue to investigate
my background. I agree to be governed by the By-Laws and any Rules
and Regulations of the Fire and Rescue company. All statements are
true to the best of my knowledge.
Signed:_______________________________ Date:______________________
Sponsor:______________________________ Date:______________________ |
|
FOR
COMPANY USE ONLY
Type Of
Membership:__________________________ Effective
Date:_________________________ |