ZCVFD.org | Zion Crossroads Volunteer Fire Department

Application for Membership
Name: *
Age:*
Date of birth*
Address:*
City:*
State:
Zip code:
Phone:*
E-mail: *
Preferred method of contact: *	Phone E-mail
Type of membership: (check all that apply) *	Fire EMS Auxiliary
Please provide a valid driver's license number or SSN for required Virginia State Police background check:*
Education and Employment
Highest level of education:
Current employer:
Work Phone:
May we contact your employer as a reference?	Yes No
Medical Conditions
Do you have any medical limitations or chronic illnesses?	Yes No
If yes, please explain:
Are you currently under doctor's care?	Yes No
If yes, please explain:
Current Certifications
Do you hold any State or National Certifications?	Yes No
If yes, please list. We will need copies of any current certifications for our records, this includes certifications like CPR.
Are you willing to take Fire AND/OR EMS training as it becomes available?	Yes No
References
Provide three references for our review. Please refrain from using family members or relatives.
#1 Name: *
#1 Phone or E-mail: *
#2 Name: *
#2 Phone or E-mail: *
#3 Name: *
#3 Phone or E-mail: *
Criminal History
Have you ever been convicted of a criminal offense? *	Yes No
If so, are you currently under indictment or facing trial for that offense?	Yes No
I desire to make application for membership in Zion Crossroads Volunteer Fire Department, pledging myself to conform to all policies and procedures of said department. To obey all orders given to me by those in authority, to answers calls, attend all meeting and department functions to the best of my ability, and to conduct myself at all times in such a manner as to no throw discredit to the department. I understand that any falsified information provided on this application can result in dismissal from the department. I also understand that Commonwealth of Virginia law requires that a criminal history record search be conducted and this will be done by the Virginia State Police.
I have read and agree to the application requirements: *	Yes

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Application for Membership

Education and Employment

Medical Conditions

Current Certifications

References

Criminal History