EASTVILLE VOLUNTEER FIRE COMPANY, INC.

16453 COURTHOUSE ROAD 

P. O.  BOX 301  EASTVILLE, VA  23347

(757) 678-7503

 

Name

Last____________________________First____________________________MI____

911 Address___________________________________________________________

P. O. Box________City____________________State________ZIP____________

 

EMPLOYMENT INFORMATION

 

Current Employer_____________________________________________________

Employer’s Address____________________________________________________

Employer’s Phone #___________________________________________________

Occupation__________________________________________________________

Employed Since____________

 

EDUCATIONAL BACKGROUND

 

High School__________________________________Grade Completed  9  10  11  12

Date of Graduation____________

College/Trade School___________________________________________________

Degrees/Certificates Earned______________________________________________

______________________________________________________________________

 

MILITARY SERVICE

 

Branch_______________________________________Dates of Service___________

Type of Discharge______________________________________________________

Occupation/Duties_____________________________________________________

Specialized Training____________________________________________________

_____________________________________________________________________   

 

FIRE TRAINING

 

Firefighter I:  [  ]                                                                                           Year Completed_______

Firefighter II:  [  ]                                                                                          Year Completed_______

EVOC:  [  ]                                                                                                    Year Completed_______

 

Other_______________________________________________________________________________

____________________________________________________________________________________ 

 

* Please attach a copy of any certification(s) to this application

 

 

Are you willing to take the training required to ensure your safety and efficient performance as a firefighter with our agency?  [  ]YES    [  ]NO

 

Current/Previous fire/ems affiliation?  [  ]YES  [  ]NO

 

If yes, which organization(s)?_______________________________________________________________________

_____________________________________________________________________________________   

 

When?_______________________________________________________________________________

_____________________________________________________________________________________   

*If you are/were a member of any fire/rescue organization within the last two years, we require that you provide a letter of recommendation from that organization with your application.

_______________________________________________________________________________________________________________

 

MOTOR VEHICLE LICENSE INFORMATION

 

Do you currently have a valid driver’s license?  [  ]YES  [  ]NO

If yes, what state?________

License #______________________________________________Class____Expiration Date________

Restrictions____________________________________________Endorsements__________________

Has your driver’s license ever been suspended or revoked?  [  ]YES  [  ]NO

If yes, when and why?_________________________________________________________________

Have you ever been convicted of a DUI?  [  ]YES  [  ]NO

If yes, when?____________________

List any traffic violations within the past five years:

_____________________________________________________________________________________
_____________________________________________________________________________________

 

*Please attach a copy of your driver’s license and driving record to this application.  You may get a copy of your driving record from the local DMV.

 

CRIMINAL HISTORY RECORD

 

The Rules and Regulations of the Board of Health, Commonwealth of Virginia, governing Emergency Services require that you have never been convicted of a felony involving any sexual crime and that you not be convicted of any act which if a felony under the laws of the State or of the United States, except that such felon is eligible for certification if within five (5) years after the date of final release, no additional felonies have been committed.

 

Have you ever been convicted of a felony?  [  ]YES  [  ]NO

If yes, explain:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever been convicted of a misdemeanor?  [  ]YES  [  ]NO

If yes, explain:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you currently on probation or assigned by a court to an Alcohol Safety Action Program or Substance Abuse Program?  [  ]YES  [  ]NO

 

*All members of this agency are required to submit to random and selective drug testing when called upon.

 

 

HEALTH AND MEDICAL HISTORY

 

The following information is obtained for assessment of firefighting and other work capabilities as part of our agency’s commitment to health and safety.  Prior to assigning members to work tasks and duties, the Eastville Volunteer Fire Company is committed to assuring that each member may perform such tasks and duties without medical restriction or undue risk to safety.

 

Height________Weight________Corrective lenses?  [  ]YES  [  ]NO

Have you been immunized against Hepatitis B?  [  }YES  [  ]NO

If yes, dates of immunizations:  1st________2nd________3rd________

*Please provide copy of shot record.

Have you ever been diagnosed with a heart attack, stroke, high blood pressure, respiratory, or other cardiopulmonary disease or disorder?  [  ]YES  [  ]NO

If yes, explain_______________________________________________________________________________

Known medical conditions___________________________________________________________________________________________________________________________________________________________________

Physical/Medical Restrictions__________________________________________________________________________________________________________________________________________________________________

Name of Physician______________________________________Phone___________________________

 

_______________________________________________________________________________________________________________

 

REFERENCES

 

NAME                                           ADDRESS                                      PHONE               RELATIONSHIP

 

1.___________________________________________________________________________________________________________________________________________________________________________

 

2.__________________________________________________________________________________________________________________________________________________________________________

 

3.__________________________________________________________________________________________________________________________________________________________________________

 

*The applicant freely and voluntarily offers himself/herself for membership in the Eastville Volunteer Fire Company, Inc. with a desire to be of service to his/her fellow mankind regardless of race, sex, creed, or nationality.  It is clearly understood by the applicant that he/she is on call at any hour, day or night, providing it does not interfere with his/her work.  If the applicant is granted membership, he/she will be governed by the Bylaws and the Standard Operating Procedures of the Eastville Volunteer Fire Company, Inc.

 

I hereby certify that all entries on all pages of this application and attachments are true and complete, and that I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any membership in the Eastville Volunteer Company, Inc.  I understand that all information on this application is subject to verification and I consent to employers, educational institutions, previous/current agency affiliations, physician, and references listed being contacted regarding this application.  I also by the NFPA (National Fire Protection Agency, Virginia Rules and Regulations, the Eastville Volunteer Fire Company Bylaws and Standard Operating Procedures, and any rules and regulations now in effect or hereafter adopted.

 

Date____________________  Applicant’s Signature__________________________________________

 

Date____________________Witness______________________________________________________

 

Text Box: DO NOT WRITE BELOW THIS LINE~AGENCY USE ONLY

 

Date Application Received____________________

 

Date Accepted by Membership for 90-day probation____________________

 

Date Accepted by Board of Directors after 90-day probation____________________

 

Comments___________________________________________________________________________________________________________________________________________________________________