| Membership applying for: |
ADMINISTRATIVE FIREFIGHTER JUNIOR |
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| Date: |
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| First Name: * |
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| Last Name: * |
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| Address Street: * * |
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| City: * |
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| Zip Code: * * |
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| State: |
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| Age: * |
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| Date Of Birth |
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| Social Security #: * |
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| Home Phone: * |
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| Cell Phone: * |
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Do you have a valid Virginia
Operators License? |
Yes No |
| Do you have a physical disability?: |
Yes No
If yes please explain:
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| Please list three references,other than relative, who can vouch for your character: |
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| Name of first reference: * |
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| Address: * |
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| Phone number: * |
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| Name of Second reference: * |
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| Address: * |
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| Phone number: * |
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| Name of third reference: * |
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| Address: * |
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| Phone number: * |
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| Are you currently a member of another Fire Company?: |
Yes No |
| Have you ever been a member of a Fire Company: |
Yes No
if yes please provide company |
| Name of Company * * * * |
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| Chief's Name / phone number |
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| list all current and previous fire related training: * |
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| Are you a member of an EMS Organization: |
Yes No
if yes please provide company |
| Name of Company |
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| Chief's Name / phone number |
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| list all current and previous fire related training: * |
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| Name of Employer / Phone number * |
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| Name of immediate supervisor: * |
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| What hours do you work?: * |
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| Have you ever been convicted of a Felony?: |
Yes No
If yes please explain:
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| Name of Physician: * |
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| Phone number: * |
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| Who should be notified in case of an emergency?: * * * |
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| Relationship: |
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| Home / Cell Phone number: |
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| I hereby certify that this is a complete record and that all entries on it are true and avvurate to the best of my knowledge. I understand that this application has to be completed in its entirety and any falsifications will be grounds of dismissal from the Company: |
By checking this box I certify that this statement is true |
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