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| Personal Information |
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| Full Name:
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Have you ever been known under different names:
Please list
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| Current Address:
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How long have you lived at above Address:
In Years
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| Home / Cell Phone Number:
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| Email Address:
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| Are you at least 18 years of age?: |
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YES
NO
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| Arson / Criminal Conviction |
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| Have you ever been convicted of the crime of Arson (in any degree)?: |
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YES
NO
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| Have you ever been convicted of a felony or of any crime (including Military): |
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YES
NO
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| If YES, please give dates and disposition::
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| Employment Information |
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Current Employer :
(If you are a student, enter your school as employer)
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| Address / City / State / Zip Code:
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| Phone Number:
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Occupation / Department (if any):
If Any?
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| Years Employed :
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| Usual Work Hours:
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| Do you do Shift Work: |
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YES
NO
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| Educational Background |
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| Are you a High School Graduate: |
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YES
NO
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| If Yes, What High School did you Attend?:
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| Do you have a GED?: |
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YES
NO
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| Are you a college graduate?: |
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YES
NO
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| If YES, What college or university did you attend?:
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| Military Service Record |
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| Were you in the U.S. Armed Forces?: |
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YES
NO
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| If YES, What branch?:
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Dates of Duty:
From : 00/00/0000
To : 00/00/0000
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| What was your Ranch at discharge?:
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| List duties in the service, including special training:
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| Firefighting / EMS Experience or Training |
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| Have you ever been a member of another Fire Dept or EMS Agency before?: |
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YES
NO
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If YES, Name of Department or Agency, and dates of service:
00/00/0000 to 00/00/0000
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Please list any previous Firefighting / EMS experience or training.:
(No previous experience or training is necessary for acceptance)
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| Personal References |
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Please list 3 personal references other than relatives:
Include - Name / Address / Phone Number
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| Digital Signature |
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| An application fee of $20.00 must be turned in at the time of your Investigations meeting. Failure to pay fee, will terminate the process. Acceptance of this application is subject to approval by the membership of this Association and Fire District. |
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| As a member of the West Webster Volunteer Firemen’s Association (the “Association”), I agree to abide by the By laws, this Membership Policy and the Code of Conduct which are designed for the benefit of all its members. |
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| I understand that participation in the Association is a privilege, and membership may be revoked with just cause. |
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| I agree that my participation in the Association will be at my sole and exclusive risk. |
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| So I (and anyone claiming on my behalf such as my estate) hold harmless the Association, its officers, directors and employees from any damages, claims, loss and liability to my participation in any program of the Association. |
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| My signature indicates that I have answered all questions truthfully, and to the best of my knowledge. It also authorizes the Fire Dist to conduct a background check. Falsification of your application is grounds for denial and or removal from membership. |
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Sign:
Entering your full legal name in this field acts as your digital signature.
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| Date :
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09/07/2024 2301 |
