Online Membership Application

 

Name:

 

Address:

 

City:

 

State:

 

Zip:

 

Telephone:

 

E-Mail:

 

Sex: 

 

Male

Female

Date of Birth:

 

 

Social Security No.:

 

Driver’s License No.:

 

Restrictions:

 

Have you ever been convicted of a crime?

 

No

Yes

 

  If so, give details:

 

What service(s) would you be interested in providing? 

 

Fire

Rescue

EMS

Support

 

 

 

 

 

 

 

 

 

Do you have any previous emergency experience? 

 

Fire

Rescue

EMS

Support

 

 

 

 

 

 

 

 

 

If so, please list certifications and details:

 

 

Please list three (3) people, not related to you, who can provide a character reference:

Name

Address

Phone

Relationship

1

2

3

 

In case of emergency, please notify:

Name:

Phone:

Relationship:

Beneficiary:

Name:

Phone:

Relationship:

 

By clicking the “Submit” button below, I am hereby making application for membership in the United Volunteer Fire & Rescue Company.  I give permission for UVFR to conduct an investigation into my background, and if accepted, promise to uphold the bylaws of the Company and to obey the officer in charge at any emergency scene or other Company function.