Lead Volunteer Fire Department

Membership Application

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APPLICANT INFORMATION
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth / MM / DD YYYY
Phone Phone - ### - ### ####
Email
Date Available Date Available / MM / DD YYYY
Are you a citizen of the United States?

Are you a citizen of the United States? Yes No
Have you been a member of the LVFD?

Have you been a member of the LVFD? Yes No
If so, when?
Have you ever been convicted of a felony?

Have you ever been convicted of a felony? Yes No
If yes, explain
Are you between the ages of 14 and 18 years old?

Are you between the ages of 14 and 18 years old? Yes No
If yes, Parent's signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
EDUCATION
High School
From From / MM / DD YYYY
To To / MM / DD YYYY
College
From From / MM / DD YYYY
To To / MM / DD YYYY
Other
From From / MM / DD YYYY
To To / MM / DD YYYY
REFERENCES

Please list three professional references.
Reference 1 Name Reference 1 Name First Last
Relationship
Phone Phone - ### - ### ####
Company
Reference 2 Name Reference 2 Name First Last
Relationship
Phone Phone - ### - ### ####
Company
Reference 3 Name Reference 3 Name First Last
Relationship
Phone Phone - ### - ### ####
Company