Membership application

First name *

Middle name

Last name *

Address *

Address

Street Address Line 1

Street Address Line 2

City

State/Province

Zip/Postal

Email *

Home phone

Cell phone

Prefered method of contact:

Email

Home phone

Cell phone

Text Message

Date of birth *

Driver's License Number

Driver's license state issued

Drivers license class

Please check all Department aspects you are interested in: *

Volunteer Firefighting

Volunteer Emergency Medical Technician

Volunteer FF/EMTVolunteer FF/EMT

Firefighter Apprentice ProgramFirefighter Apprentice Program

Part-Time Paid Staff (requires previously obtained: NC FF Certification, NC EMS Certification)

Career Full-Time Paid Staff (requires previously obtained: NC FF Certification, NC EMS Certification)Career Full-Time Paid Staff (requires previously obtained: NC FF Certification, NC EMS Certification)

Junior Program (ages 16-18)

Auxiliary Team

Board Of Directors

Please list any prior Fire, Rescue, Emergency Medical Traing experience you have:

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High school

School name

School city

School state

Date completed

Graduated?

Yes

No

College

School name

School city

School state

Date completed

Graduated?

Yes

No

Other Education

School name

School city

School state

Date completed

Graduated?

Yes

No

Military Experience

Branch of service

Reserve status

Attendance requirements

Employment History

Employer name *

Employer's address *

Employer's phone *

Supervisor's name *

Supervisor's phone *

Supervisor's email address *

Working hours *

Date of hire *

Specific job duties *

May we contact your employer?

Yes

No

Personal References

List 3 people we may contact for a personal reference

Reference name *

Reference phone *

Reference email address *

Reference address *

Reference address

Street Line 1

Street Line 2

City

State/Province

Zip/Postal

Reference name *

Reference phone *

Reference email address *

Reference address *

Reference address

Street Line 1

Street Line 2

City

State/Province

Zip/Postal

Reference name *

Reference phone *

Reference email address *

Reference address *

Reference address

Street Line 1

Street Line 2

City

State/Province

Zip/Postal

List any criminal convictions and traffic violations:

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Thank you for your interest in becoming a member of Waxhaw Volunteer Fire Department.

High school

College

Other Education

Military Experience

Employment History

Personal References

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