Maryville fire dept application

Application for Membership

Maryville Village Fire Department
Full Name*

First NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address*
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
Work Number

Area CodePhone Number
Drivers License #*
Have you lived in the Village of Maryville or the Maryville Fire Protection District for at least 1 year?*
Present Health Condition?*
Marital Status*
Have you had a major illness within the last 5 years?*
If yes to above, please describe:
Are you willing to submit to a pre-membership physical?*
Present Occupation?*
Work Hours:*
Have you been convicted of a crime within the last 3 years?*
If Yes to above, please describe:
List any previous Firefighting, Rescue, or Medical Experience:*
List any other experiences, skills, or qualification that you feel will be beneficial for your membership to this department:*
What interests you about the Fire Department? What made you apply for membership?*
I, the undersigned having herby made application for membership to the Maryville Village Fire Department, declare if accepted, I will obey and be governed by the rules and regulations of the Department, and also understand that any false statements of this application shall be grounds for immediate dismissal.
Date:*

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Signature

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Application for Membership