Language
English (US)
Manassas Volunteer Fire Company, Inc.
9322 Centreville Road, Manassas VA 20110
Today's Date
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-
Month
-
Day
Year
Name
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Last
First
Middle
Suffix
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Alternate Phone Number
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Area Code
Phone Number
Email
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example@example.com
Date of Birth
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Month
-
Day
Year
Date
Citizenship
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Drivers License #
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State
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Hight
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Weight
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Hair Color
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Blood Type
Sex
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Male
Female
Eye Color
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Last 4 digits of Social Security number
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Education
High School Attended
Graduated
Yes
No
GED
Yes
No
Date Graduated
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Month
-
Day
Year
Date
College Attended
Medical Information
Do you have any physical or medical conditions or illnesses that might prevent your full participation in fire company activities? If yes please explain.
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Yes
No
Have you ever had epilepsy or any other mental or nervous ailment, or been a patient in an institution for treatment of such ailment? If Yes, Please explain.
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Yes
No
Emergency Contact Information
Name
*
First Name
Last Name
Relationship
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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-
Area Code
Phone Number
Employment History
Emergency Services Experiance
Have you every been a member or employee of another fire rescue organization? If Yes, Where?
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Yes
No
Have you ever been removed from or refused membership in this any other fire rescue organization? If Yes, please explain.
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Yes
No
List any fire rescue / emergency medical training you posses which might make you a more valuable member of this company.
Do you currently hold any of the following Emergency services certifications?
Firefighter I
Firefighter II
RIT / Mayday
Hazmat Ops
ARFF
DPO
CPR
EMT-B
Do you have any of the following FEMA certifications?
ICS-100
ICS-200
ICS-700
ICS-800
Please list any other fire rescue certifications you may have and dates of expiration.
Background information
Do you have any objection to the Manassas Volunteer Fie Company inc. Checking with present and former employers as to your character and qualifications?
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Yes
No
If separated from the armed forces, was the separation under other than honorable circumstances?
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Yes
No
N/A
Prior to submission of this application were any of the members of this fire company personally known to you? If yes please list below.
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yes
No
Have you ever had you drivers license suspended or revoked?
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Yes
No
Have you ever been arrested for any violation other that minor traffic violations? If yes, please explain.
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Yes
No
Do you Realize?
That, if you are elected to the Manassas Volunteer Fire Company, Inc. It will be on a 6 month trial basis after which time the line offices of the company will make a recommendation to the membership who will vote on permanent membership in the company?
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Yes
No
that, if elected to probationary membership, you shall be expected to comply with all of the by-laws of the company or risk loss of membership?
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Yes
No
That your attendance will be required at the fire company activities, resulting in considerable demands upon your time?
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Yes
No
That being a member does not give you any special privileges with respect to obeying all speed limits, traffic signals / devices when answering fire calls?
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Yes
No
That you shall be expected to complete (at company expense) a physical examination before being voted for probationary membership?
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Yes
No
That all members are expected to regularly attend scheduled drills?
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Yes
No
That no member of the company shall appear at a company meeting, report for duty or respond on any call while under the influence of alcohol or drugs, nor shall a member use insulting, indecent or otherwise improper language while representing the company in any capacity or while participating in any company function under penalty of expulsion?
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Yes
No
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