Online application

STRASBURG FIRE

DEPARTMENT

Online application

All information is confidential and will not be shared with anyone

Strasburg Fire Department Online Application

I respectfully make application for membership in the Strasburg Fire Department Inc. I will be governed by the Constitution and By-Laws of the Company, and pledge my loyal support for its future welfare and success. It is understood that I will enter the company as a probationary member until I have been properly trained and have been a member for six (6) months

Membership Type: (Junior, Firefighter, Administrative)

Date:
First Name:
Last Name:
Street Address:
City:
Zip Code:
State::
Date Of Birth:
Social Security Number:
Home Phone:
Cell Phone:

Do you have a valid Virginia Operators License?:
Do you Have a Physical Disability?:
-If yes please explain:
List three References other than relatives:

Name of First reference:
Address:
Phone Number:

Name of second reference:
Address:
Phone number:

Name of third reference:
Address:
Phone number:

Are you currently a member of another Fire Dept. Yes or No
Have you ever been a member of another Fire Dept. Yes or No
If yes please provide company name:
Name of Company:
Chiefs Name:
Chief's phone number:
List all current and previous fire related trainings:




Are you a member of EMS Organization: Yes or No
If yes please provide Name of Company:
Name of Company:
Chiefs Name:
Chiefs Number:
List all current and previous EMS related trainings:

Name of Employer:
Phone Number:
Name of Immediate Supervisor:
What hours do you work?:

Have you ever been convicted of a felony?: Yes or No
If yes please explain?:

Name of Physician:
Phone Number:

Who should be notified in case of emergency?:
Relationship::
Phone number:
I hereby certify that this is a complete record and that all entries on it are true and accurate to the best of my knowledge. I understand that this application has to be completed in its entirety and any falsifications will be grounds of dismissal from the Company::

please leave any information that you feel that SFD needs to know: