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EASTVILLE VOLUNTEER FIRE COMPANY, INC. 16453 COURTHOUSE ROAD P. O. BOX 301 EASTVILLE, VA 23347 (757) 678-7503
Name Last____________________________First____________________________MI____ 911 Address___________________________________________________________ P. O. Box________City____________________State________ZIP____________
EMPLOYMENT INFORMATION
Current Employer_____________________________________________________ Employer’s Address____________________________________________________ Employer’s Phone #___________________________________________________ Occupation__________________________________________________________ Employed Since____________
EDUCATIONAL BACKGROUND
High School__________________________________Grade Completed 9 10 11 12 Date of Graduation____________ College/Trade School___________________________________________________ Degrees/Certificates Earned______________________________________________ ______________________________________________________________________
MILITARY SERVICE
Branch_______________________________________Dates of Service___________ Type of Discharge______________________________________________________ Occupation/Duties_____________________________________________________ Specialized Training____________________________________________________ _____________________________________________________________________
FIRE TRAINING
Firefighter I: [ ] Year Completed_______ Firefighter II: [ ] Year Completed_______ EVOC: [ ] Year Completed_______
Other_______________________________________________________________________________ ____________________________________________________________________________________
* Please attach a copy of any certification(s) to this application
Are you willing to take the training required to ensure your safety and efficient performance as a firefighter with our agency? [ ]YES [ ]NO
Current/Previous fire/ems affiliation? [ ]YES [ ]NO
If yes, which organization(s)?_______________________________________________________________________ _____________________________________________________________________________________
When?_______________________________________________________________________________ _____________________________________________________________________________________ *If you are/were a member of any fire/rescue organization within the last two years, we require that you provide a letter of recommendation from that organization with your application. _______________________________________________________________________________________________________________
MOTOR VEHICLE LICENSE INFORMATION
Do you currently have a valid driver’s license? [ ]YES [ ]NO If yes, what state?________ License #______________________________________________Class____Expiration Date________ Restrictions____________________________________________Endorsements__________________ Has your driver’s license ever been suspended or revoked? [ ]YES [ ]NO If yes, when and why?_________________________________________________________________ Have you ever been convicted of a DUI? [ ]YES [ ]NO If yes, when?____________________ List any traffic violations within the past five years: _____________________________________________________________________________________
*Please attach a copy of your driver’s license and driving record to this application. You may get a copy of your driving record from the local DMV.
CRIMINAL HISTORY RECORD
The Rules and Regulations of the Board of Health, Commonwealth of Virginia, governing Emergency Services require that you have never been convicted of a felony involving any sexual crime and that you not be convicted of any act which if a felony under the laws of the State or of the United States, except that such felon is eligible for certification if within five (5) years after the date of final release, no additional felonies have been committed.
Have you ever been convicted of a felony? [ ]YES [ ]NO If yes, explain:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Have you ever been convicted of a misdemeanor? [ ]YES [ ]NO If yes, explain:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Are you currently on probation or assigned by a court to an Alcohol Safety Action Program or Substance Abuse Program? [ ]YES [ ]NO
*All members of this agency are required to submit to random and selective drug testing when called upon.
HEALTH AND MEDICAL HISTORY
The following information is obtained for assessment of firefighting and other work capabilities as part of our agency’s commitment to health and safety. Prior to assigning members to work tasks and duties, the Eastville Volunteer Fire Company is committed to assuring that each member may perform such tasks and duties without medical restriction or undue risk to safety.
Height________Weight________Corrective lenses? [ ]YES [ ]NO Have you been immunized against Hepatitis B? [ }YES [ ]NO If yes, dates of immunizations: 1st________2nd________3rd________ *Please provide copy of shot record. Have you ever been diagnosed with a heart attack, stroke, high blood pressure, respiratory, or other cardiopulmonary disease or disorder? [ ]YES [ ]NO If yes, explain_______________________________________________________________________________ Known medical conditions___________________________________________________________________________________________________________________________________________________________________ Physical/Medical Restrictions__________________________________________________________________________________________________________________________________________________________________ Name of Physician______________________________________Phone___________________________
_______________________________________________________________________________________________________________
REFERENCES
NAME ADDRESS PHONE RELATIONSHIP
1.___________________________________________________________________________________________________________________________________________________________________________
2.__________________________________________________________________________________________________________________________________________________________________________
3.__________________________________________________________________________________________________________________________________________________________________________
*The applicant freely and voluntarily offers himself/herself for membership in the Eastville Volunteer Fire Company, Inc. with a desire to be of service to his/her fellow mankind regardless of race, sex, creed, or nationality. It is clearly understood by the applicant that he/she is on call at any hour, day or night, providing it does not interfere with his/her work. If the applicant is granted membership, he/she will be governed by the Bylaws and the Standard Operating Procedures of the Eastville Volunteer Fire Company, Inc.
I hereby certify that all entries on all pages of this application and attachments are true and complete, and that I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any membership in the Eastville Volunteer Company, Inc. I understand that all information on this application is subject to verification and I consent to employers, educational institutions, previous/current agency affiliations, physician, and references listed being contacted regarding this application. I also by the NFPA (National Fire Protection Agency, Virginia Rules and Regulations, the Eastville Volunteer Fire Company Bylaws and Standard Operating Procedures, and any rules and regulations now in effect or hereafter adopted.
Date____________________ Applicant’s Signature__________________________________________
Date____________________Witness______________________________________________________
Date Application Received____________________
Date Accepted by Membership for 90-day probation____________________
Date Accepted by Board of Directors after 90-day probation____________________
Comments___________________________________________________________________________________________________________________________________________________________________
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