Cool SpringsVolunteer Fire Dept.

Application for Membership

Cool Springs Volunteer Fire Department

Please complete all sections carefully. Fields marked with * are required.

Personal Information

First Name *

Middle Name

Last Name *

Address *

City *

State *

Zip *

Date of Birth *

Age

Cell Phone *

Email *

Social Security Number *

DL Number *

Class *

Expires (MM/YYYY) *

State Issued *

DL Restrictions *

DL Endorsements *

Education Level *

School Name *

Year Graduated *

Emergency Contact Name *

Contact Number *

Relationship *

Background Check Information

These fields are used for the background check release form.

Other Names Used in Last 7 Years (Maiden Name) *

County *

Gender *

Race *

Employment

Employer *

City *

Position *

Medical History

Do you currently have any medical problems?

Do you have any physical handicap that may affect your ability to perform fire service duties?

Are you currently allergic to anything that would cause the use of Epinephrine (EPI)?

Personal History

Have you ever served in the United States Military?

Do you have a license, certificate, or authorization to practice a trade or profession?

Do you have any previous first aid or CPR training?

Do you have any previous firefighting or EMS experience?

Have you ever received any traffic violations?

Availability

These are department requirements. Check each box to confirm your agreement. If you cannot agree, provide an explanation.

Are you available for emergency calls during the day?

This is a department requirement. If you cannot agree, please explain why. *

Are you available for emergency calls during the evening?

This is a department requirement. If you cannot agree, please explain why. *

Are you willing to attend training classes and drills?

This is a department requirement. If you cannot agree, please explain why. *

Are you willing to participate in public relation events?

This is a department requirement. If you cannot agree, please explain why. *

Will you abide by the By-laws and Rules of the Cool Springs VFD?

This is a department requirement. If you cannot agree, please explain why. *

Will you uphold the Cool Springs VFD and its members in the highest esteem and respect?

This is a department requirement. If you cannot agree, please explain why. *

Will you take care of all department-issued equipment and report any problems?

This is a department requirement. If you cannot agree, please explain why. *

Reference

Name

Phone

Address

Relationship

Acknowledgements

I understand that answering the questions above does not automatically disqualify me from becoming a member of Cool Springs Volunteer Fire Department.

I acknowledge that by completing the background check at the Iredell County Sheriff's Office, my criminal records will be sent directly to Cool Springs VFD. I also acknowledge that the fee charged is not paid for or reimbursed by the department.I hereby certify that the information contained in this application is true to the best of my belief and knowledge. Permission is given to the Cool Springs Volunteer Fire Department to verify any and all information. *

Signature (Full Name) *

Date