Membership Application

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Membership Application

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- Step 1 of 6

Membership Classification*

Regular (Fire or Fire/EMS)
EMS Only
Administrative
Associate
Junior

Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Date of Birth* *

Social Security Number *

Email *

Sex

Race

Occupation

Employer's Name

Employer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer's Phone

Medical Conditions

Emergency Contact Person* *

First

Last

Emergency Contact Phone*

Relationship

Drivers License*

Do you have a valid Motor Vehicle Operators License?

Drivers License Number

Drivers License State

Drivers License Class

Current Points (if applicable)

Are you now or have you ever been a member of any Fire Company and/or Rescue Squad?

Do you belong to any other organizations?

Have you ever been convicted of any crime other than a traffic violation?

List someone NOT related to you: *

First

Last

Phone

List someone NOT related to you:

First

Last

Phone

Birth* any Committee

Do you have any objection to the Membership Committee verifying any and all statements concerning this application?

In a brief statement, please explain why you want to become a member of the Church Hill Volunteer Fire Company.

I, the undersigned hereby declare all statements and information in this application are true and complete, and understand that any untrue, misleading answer or deliberate omission or concealment may be grounds for refusal of membership in the Church Hill Volunteer Fire Company, Inc. I, the undersigned authorize the Church Hill Volunteer Fire Company, Inc. to conduct a background investigation and to communicate with any individual or organization listed in this application for the purpose of investigating or confirming my character, conduct or record and to keep and preserve records of such communications. Additionally, I release all parties from all liability for damage that may result from furnishing any information. If accepted for membership, I agree to read and abide by the Constitution & By-Laws of the Church Hill Volunteer Fire Company, Inc. and any and all Standard Operating Guidelines, House Rules, Directives and any other rules and regulations adopted by the Fire company. I further agree that upon termination of my membership with the Church Hill Volunteer Fire Company, Inc. I will return all Fire company property entrusted to me.

I agree to the above information *

I agree to the above information