Application

 

 

APPLICATION FOR MEMBERSHIP

MARLBOROUGH VOLUNTEER FIRE CO., INC.

 

APPLICATION FOR:        MVFD          AMBULANCE        EXPLORER         AUXILARY

 

NAME: _____________________________________________________________  DATE:_____________

                 (last)                                              (first)                        (middle)

ADDRESS: ________________________________________________________ PHONE #: ____________

                     (street)                                              (city)                            (zip)

AGE: _____  DATE OF BIRTH: _____________  SOCIAL SECURITY NUMBER:  _____/___/______

OCCUPATION: ___________________________ SHIFT: _____________

PREVIOUS ADDRESS (if applicable):  ________________________________________________________

_________________________________________________________________________________________

PREVIOUS FIRE FIGHTING EXPERIENCE:        YES        NO

PREVIOUS EMS EXPERIENCE:                           YES        NO

NAME OF ORGANIZATION: _______________________________________________________________

CONTACT PERSON: ___________________________________  PHONE#: _________________________

LENGTH OF PRIOR SERVICE EXPERIENCE:  _____  FROM: _____________ TO: ______________

 


U.S. MILITARY SERVICE:       YES      NO  BRANCH: ________________  FROM: ________ TO: _______

RANK: _____________  TYPE OF DISCHARGE: ________________________________________________

 

EVER CONVICTED OF A FELONY:       YES          NO

ARE YOU INVOLVED IN ANY LITGATION AT THIS TIME:       YES        NO

DRIVERS LICENSE NUMBER: __________________________________  CLASS: ___________________

MOTOR VEHICLE MOVING VIOLATIONS DURING THE LAST 3 YEARS:  _______________________

LIST ANY KNOWN DISABILITIES: _________________________________________________________

__________________________________________________________________________________________

 

WHY WOULD YOU LIKE TO BECOME A MEMBER OF THE MVFD?

__________________________________________________________________________________________

__________________________________________________________________________________________

 

LIST THREE REFERENCES (not relatives) YOU HAVE KNOWN FOR FIVE OR MORE YEARS

                 NAME                                 ADDRESS                                     PHONE         OCCUPATION

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

 

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CERTIFICATION, AUTHORIZATION and RELEASE

 

I understand that membership with the MVFD, if offered, is contingent upon my passing a physical exam, and providing additional information for record purposes.  In addition, my membership is terminable at will, and I will comply with, and be governed by, all MVFD published policies and procedures as may be in effect from time to time.

 

I certify that the information given by me in this application is correct, and I understand and agree that consideration of this application for membership with the MVFD may be discontinued if material misrepresentations or omissions are found to have been made.

 

I authorize investigation of data given by me on this membership application and to provide any and all information pertinent to my membership of the MVFD and hereby release those providing such information from any liability for doing so.

 

SIGNED: __________________________________________________________    DATE: ________________

SPONSORED BY: ___________________________________________________   DATE: ________________

 

COMMENTS: _______________________________________________________________________________

____________________________________________________________________________________________