FLINT HILL VOLUNTEER FIRE & RESCUE COMPANY

First Name and Middle Initial

Last Name

Date of Birth

Email Address

Telephone Number

Alternate Telephone Number (type N/A if none)

Citizenship

Last 4 Digits of Social Security Number

Driver's License State

Driver's License Number

Street Address

Mailing Address (if different than Street Address; if the same type SAME)

Do you have any physical or medical conditions or illnesses that might prevent your full participation in Company 4 actives? Do you have any physical or medical conditions or illnesses that might prevent your full participation in Company 4 actives? Yes No

If YES, please explain. If NO, type "None."

Have you ever been a member or employee of another fire or rescue organization? Have you ever been a member or employee of another fire or rescue organization? Yes No

If YES, please explain. If NO, type N/A.

If YES, have you ever been removed from or refused membership in the above company(s) or any other fire or rescue organization? If YES, have you ever been removed from or refused membership in the above company(s) or any other fire or rescue organization? Yes No

If YES, please explain. If NO, type N/A.

Do you currently hold any of the following Fire/Rescue Emergency services certifications? (check all that apply.) Do you currently hold any of the following Fire/Rescue Emergency services certifications? (check all that apply.) CPR Firefighter I Firefighter II Officer I / II EMT - Basic Paramedic Emergency Vehicle Operator I / II / III Driver Pump Operator Hazmat Awareness of Operations

Do you have any of the following FEMA Incident Command System certifications? (check all that apply) Do you have any of the following FEMA Incident Command System certifications? (check all that apply) ISC- 100 ISC- 200 ISC- 700 ISC- 800

Please list any other experience, paid or volunteer, that you feel might benefit Flint Hill Volunteer Fire & Rescue. Examples include but are not limited to: accounting, grant writing, fundraising, food preparation/cooking, facility cleaning, lawn & grounds maintenance, organizational skills, medical care experience, etc. Please know that Company 4 encourages all who qualify and who are willing to volunteer their time to apply. Please list any other experience, paid or volunteer, that you feel might benefit Flint Hill Volunteer Fire & Rescue. Examples include but are not limited to: accounting, grant writing, fundraising, food preparation/cooking, facility cleaning, lawn & grounds maintenance, organizational skills, medical care experience, etc. Please know that Company 4 encourages all who qualify and who are willing to volunteer their time to apply.

List Experience Here. If none, type NONE.

Are you an active or separated member of the US military? Are you an active or separated member of the US military? Yes No

If separated, was the separation under other than honorable circumstances? If separated, was the separation under other than honorable circumstances? Yes No Not Applicable

Have you ever had your vehicle driver’s license suspended or revoked? Have you ever had your vehicle driver’s license suspended or revoked? Yes No

If YES, please explain. If NO, type N/A.

Have you ever been arrested for any violation other that minor traffic violations? Have you ever been arrested for any violation other that minor traffic violations? Yes No

If YES, please explain. If NO, type N/A.

Personal References: Please provide three-character references unrelated to you. Personal References: Please provide three-character references unrelated to you.

Reference No. 1 Name, Address, Telephone Number

Reference No. 2 Name, Address, Telephone Number

Reference No. 3 Name, Address, Telephone Number

I acknowledge: 1) If I am elected to Company 4, it will be on a 6-month probationary basis after which time the Board of Directors and/or membership committee of the Company will make a recommendation to the membership who will vote on permanent membership status. 2) If I am elected to probationary membership status, I shall be expected to comply with all Company 4 by-laws or risk an extended probationary period or loss of membership. 3) My attendance will be required at Company 4 activities, resulting in periodic demands upon my time. 4) All operational members are expected to regularly attend scheduled training. NOTE: A background check and driver’s license check are required for all applicants. The undersigned applicant agrees to indemnify and hold harmless Company 4, its officers and directors and employees, from any consequence resulting from this application and the revelation of any information therein, including but not limited to any third-party actions claiming injury based on this application and the revelation of any information therein. Further, applicant agrees to indemnify and hold harmless sources of information regarding the applicant, including but not limited to references and other fire and rescue organizations and their members. I acknowledge: 1) If I am elected to Company 4, it will be on a 6-month probationary basis after which time the Board of Directors and/or membership committee of the Company will make a recommendation to the membership who will vote on permanent membership status. 2) If I am elected to probationary membership status, I shall be expected to comply with all Company 4 by-laws or risk an extended probationary period or loss of membership. 3) My attendance will be required at Company 4 activities, resulting in periodic demands upon my time. 4) All operational members are expected to regularly attend scheduled training. NOTE: A background check and driver’s license check are required for all applicants. The undersigned applicant agrees to indemnify and hold harmless Company 4, its officers and directors and employees, from any consequence resulting from this application and the revelation of any information therein, including but not limited to any third-party actions claiming injury based on this application and the revelation of any information therein. Further, applicant agrees to indemnify and hold harmless sources of information regarding the applicant, including but not limited to references and other fire and rescue organizations and their members. Acknowledged and Agreed

Applicant Signature (type your name here as signature)

Date

Junior Membership Parent or Legal Guardian Approval (Complete only for applicants ages 16-18) Junior Membership Parent or Legal Guardian Approval (Complete only for applicants ages 16-18)

Parent Signature (type your name here as signature)

Parent Telephone Number