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| Personal Information |
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Name:
Last, First, Middle
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| Address:
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| City/State:
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| Zip Code:
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| Has this been your residence for the last 5 years?: |
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Yes
No
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| If no, where did you reside?:
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| Home Phone:
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| Cell Phone:
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| Work Phone:
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| Email:
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| Preferred Method of Contact:
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| Date of Birth:
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| Sex: |
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Male
Female
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| Age:
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| Marital Status:
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| Height:
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| Weight:
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| Hair Color:
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| Eye Color:
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| Are you a citizen of the United States?: |
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Yes
No
Resident Foreign National
Non-Resident Foreign National
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| Ethnicity: |
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Asian
American Indian or Alaskan Native
Black or African American
Hispanic or Latino
Native Hawaiin or Pacific Islander
White
Other
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| Occupation:
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| Duties:
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| Employer Name:
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| Employer Address:
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| Have you ever served in the armed forces?: |
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Yes
No
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| If Yes, which branch?:
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| Type of Discharge:
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| Do you a history of any of the following?:
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Respiratory Distress
Epilepsy or Seizures
Heart Disease
Asthma
None
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| Previous History of any medical problem that will impair your service in this department: |
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Yes
No
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| Have you ever been convicted (Felony or Misdemeanor) of any violation of the law, excluding minor traffic violations?: |
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Yes
No
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If Yes, please describe:
Please include the date, court, and disposition
of the case, and include any cases in which you were given probation before judgment (or a similar finding in a state other than Maryland) (Conviction of a crime is not cause for an automatic barring to membership. Each case is considered on its own merit. Persons with record(s) of arrest and convictions may hold membership within this department.)
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| Drivers License No:
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| State of Issue:
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| License Class:
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| Date of Issue:
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| Expiration Date:
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| Have you ever held a drivers license in another state?: |
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Yes
No
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If Yes:
State, License No, Class
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| Experience |
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| Have you ever been a member of this or any other fire department?: |
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Yes
No
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If Yes, Name of Department:
You must submit a letter of recommendation from a chief officer.
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| Are you planning on maintaining dual membership?: |
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Yes
No
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| If the other station is in Howard County select a "Home Station":
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| Have you ever had any previous firefighting or emergency medical training?: |
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Yes
No
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If Yes, Please explain and list any certifications and dates taken:
Attach copies to this application
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| Have you ever been rejected, suspended, or expelled from this or any fire department or rescue group?: |
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Yes
No
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| If Yes, Please Explain and What Department:
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| Why would you like to be a member of the Lisbon Volunteer Fire Company?:
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| How did you hear about us?:
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| Emergency Contacts |
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| 1st Emergency Contact Name:
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| 1st Emergency Contact Relationship:
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| 1st Emergency Contact Phone No:
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| 1st Emergency Contact Address:
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| 2nd Emergency Contact Name:
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| 2nd Emergency Contact Relationship:
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| 2nd Emergency Contact Phone No:
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| 2nd Emergency Contact Address:
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| References |
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Reference 1 Name:
One Reference can be a member of the department
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| Reference 1 Phone:
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| Reference 2 Name:
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| Reference 2 Phone:
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| Are you applying to be an Operational or Non-Operational (administrative) member?: |
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Operational
Non-Operational
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| Attach any additional documentation to your application:
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| Signature |
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| Type your name to sign your Application:
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| If under 18 provide name and number of a Parent/Guardian:
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By clicking submit you agree to the following statements:
I do promise to abide by all laws and rules relating with the Lisbon Volunteer Fire Company, Inc.
I, the undersigned, will be required to appear before the membership committee for an initial interview.
I, the undersigned, understand that should my application for membership be accepted by the members of the LVFC, I shall be on a 365 day probation period.
I, the undersigned, understand that any knowingly false statement to any of the foregoing herein will result in the rejection of the application for membership or possible termination if membership was already granted.
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