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Membership Application
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Membership Application
Please complete the form below and a member of our team will be in touch.
Step
1
of
6
16%
Section I
Membership Classification
*
Regular (Fire or Fire/EMS)
EMS Only
Administrative
Associate
Junior
Name
*
First
Middle
Last
Address
*
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Date of Birth
*
MM slash DD slash YYYY
Email
*
Enter Email
Confirm Email
Sex
*
Male
Female
Race
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Section II
Occupation
Employer's Name
Employer's Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer's Phone
Medical Conditions
List any medical conditions that may affect your performance or limit your duties in this Fire Company:
Physician's Name
First
Last
Physician's Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Physician's Phone
Emergency Contact Person
*
First
Last
Emergency Contact Address
*
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Emergency Contact Phone
*
Relationship
*
Section III
Drivers License
*
Do you have a valid Motor Vehicle Operators License?
Yes
No
Drivers License Number
Drivers License State
Drivers License Class
Current Points (if applicable)
Section IV
Prior Member?
*
Are you now or have you ever been a member of any Fire Company and/or Rescue Squad?
Select One
Yes
No
Company Name
Please list company name and address, as well as when you were a member.
Why did you leave that organization? If you are still a member, please indicate so.
Why did you leave that organization? If you are still a member, please indicate so.
List any training & certifications and/or experience that you may have received in firefighting, EMS or rescue operations.
List any training & certifications and/or experience that you may have received in firefighting, EMS or rescue operations.
Files
Upload any pertinent certifications. ( .jpg, .jpeg, .pdf, .doc, .docx )
Drop files here or
Select files
Accepted file types: jpg, jpeg, pdf, doc, docx, Max. file size: 50 MB, Max. files: 3.
Other Organizations?
Do you belong to any other organizations?
Select One
Yes
No
Please list other organizations.
Please list other organizations.
Select One
*
Have you ever been convicted of any crime other than a traffic violation?
Select One
Yes
No
List below any convictions and dates:
List below any convictions and dates:
Section V
Reference #1
*
List someone NOT related to you:
First
Last
Phone
*
Reference #2
*
List someone NOT related to you:
First
Last
Phone
*
Reference #3
*
List someone NOT related to you:
First
Last
Phone
*
Do you have any objection to the Membership Committee verifying any and all statements concerning this application?
*
Do you have any objection to the Membership Committee verifying any and all statements concerning this application?
Yes
No
In a brief statement, please explain why you want to become a member of the Church Hill Volunteer Fire Company.
*
In a brief statement, please explain why you want to become a member of the Church Hill Volunteer Fire Company.
Section VI
I, the undersigned hereby declare all statements and information in this application are true and complete, and understand that any untrue, misleading answer or deliberate omission or concealment may be grounds for refusal of membership in the Church Hill Volunteer Fire Company, Inc.
I, the undersigned authorize the Church Hill Volunteer Fire Company, Inc. to conduct a background investigation and to communicate with any individual or organization listed in this application for the purpose of investigating or confirming my character, conduct or record and to keep and preserve records of such communications. Additionally, I release all parties from all liability for damage that may result from furnishing any information.
If accepted for membership, I agree to read and abide by the Constitution & By-Laws of the Church Hill Volunteer Fire Company, Inc. and any and all Standard Operating Guidelines, House Rules, Directives and any other rules and regulations adopted by the Fire company. I further agree that upon termination of my membership with the Church Hill Volunteer Fire Company, Inc. I will return all Fire company property entrusted to me.
Consent
*
I agree to the above information
Name
This field is for validation purposes and should be left unchanged.
Δ
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