*
First Name		 *
M.I.		 *
Last Name
Suffix
 
*
Home Telephone (Include Area Code)		 *
Date of Birth (mm/dd/yy)
   

Cell or Other Phone (Include Area Code)		 *
Social Security Number (Include Dashes)
   

E-Mail Address		  
 
*
Address
Apartment (If Applicable)
 
*
City		  *
State		  *
ZIP
 
*
Years at this Address		 If at this address less than 1 year, please provide previous address information below.
 

Previous Address
Apartment (If Applicable)
 

City
State
ZIP
 
 
 
Name & Address of Institution  *
 
Type of Institution  *
 
Dates Attended     to    *
 
Did You Graduate?  Yes   No  *
 
Diploma, Degree, or Certificate Obtained
 
   
Name & Address of Institution
 
Type of Institution
 
Dates Attended
 		    to  
Did You Graduate?
 		 Yes   No
Diploma, Degree, or Certificate Obtained
 
   
Name & Address of Institution
 
Type of Institution
 
Dates Attended
 		    to  
Did You Graduate?
 		 Yes   No
Diploma, Degree, or Certificate Obtained
 
 
 
 
Have you ever been convicted of a moving traffic violation, misdemeanor, or felony?  If yes, explain.  (Answering yes will not necessarily eliminate you from membership eligibility)
 		Yes
 No   *
   
Have you been charged with or are you currently under indictment for any crime that has not yet been resolved in court?  If yes, explain.
 		Yes
 No   *
   
If asked to do so, would you be willing to submit to a physical medical examination? Yes
 No   *
   
Do you have any medical issues, health concerns, or physical disabilities that may interfere with your ability to fully perform all fire and rescue duties?  If so, please explain.
 		Yes
 No   *
   
Do you understand that by becoming a member of this Department that you agree to voluntarily submit to initial, random, and "for cause" drug and/or alcohol screening? Yes
 No   *
   
By checking the box and entering my initials below I give the Buckhall Volunteer Fire and Rescue Department permission to check my driving records and criminal history records at their discretion.  

 *   I agree to allow the Buckhall Volunteer Fire and Rescue Department to run driving record and criminal record background checks. 
*   Your initials here
 
 
 

Current Employer
   
Employer:  *
Phone:  *
Address
(Include City, State, ZIP):		  *
   
Supervisor Name:  *
Supervisor Phone:  *
   
Dates of Employment:     to    *
   
Position:  *
   
Reason for Leaving:
 
 

Previous Employer
   
Employer:
Phone:
Address
(Include City, State, ZIP):
   
Supervisor Name:
Supervisor Phone:
   
Dates of Employment:    to  
   
Position:
   
Reason for Leaving:
 
 

Previous Employer
   
Employer:
Phone:
Address
(Include City, State, ZIP):
   
Supervisor Name:
Supervisor Phone:
   
Dates of Employment:    to  
   
Reason for Leaving:
 
 
 
Type of Membership Desired:  *
   
Have you ever been a member of another fire or rescue department? Yes
 No   *
   
If yes, where?
   
Dates of Membership:    to  
   
   
Have you ever been removed from or refused membership in another fire or rescue agency? Yes
 No   *
   
If yes, where?
   
For what reason?
   
Date of refusal or termination:
 
 
 
Certification (Type and Level): State Expiration Date:
 
 
 
Name:  *
Relationship:  *
Address
(Include City, State, ZIP):		  *
Phone:  *
Best Time to Call:  *
Occupation:  *
Years Known:  *
   
Name:  *
Relationship:  *
Address
(Include City, State, ZIP):		  *
Phone:  *
Best Time to Call:  *
Occupation:  *
Years Known:  *
   
Name:
Relationship:
Address
(Include City, State, ZIP):
Phone:
Best Time to Call:
Occupation:
Years Known:  
 
 
 
I hereby certify that the information contained herein is accurate sand complete to the best of my knowledge.  I understand that should any information provided prove false, misleading, or erroneous, my application may be rejected.  If any information should be determined to be false after I am accepted for membership, my membership may be terminated.

Certify your agreement to these terms by typing your full name in the box below:

 *
Type your full name above