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| PERSONAL |
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| Submitted on:
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10/22/2021 0328 |
| Volunteer Preference :
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| Department Interested in Joining:
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| Last Name:
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| First Name:
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| Middle Name:
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| Are you under 18 years of age? : |
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Yes
No
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| Date of Birth:
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| E-mail Address :
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| Street Address:
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| City, State, Zip:
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| Home Phone:
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| Cell Phone:
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| Gender:
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| Have you ever held a Virginia Driver's License?:
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| Drivers License #:
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| Highest Education Obtained:
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| CRIMINAL HISTORY |
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| Have you ever been convicted of a felony? :
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| Have you ever been a subject of a complaint regarding neglect of an animal, child, the elderly, or anyone in your care?:
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| Do you have any traffic violations in the last 3 years?:
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| If you answered yes to any of the previous questions please explain.:
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| EXPERIENCE |
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| Have you been affiliated with any other fire and rescue organizations within the past 3 years?:
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| What is your primary occupation?:
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| Please provide any previous fire departments or rescue organizations that you have been a member of |
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| Department #1:
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| Department #2:
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| Department #3:
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| REFERENCES (Please list name, address and home & work phone numbers |
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| Reference #1:
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| Reference #2:
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| Reference #3:
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| ACKNOWLEDGEMENT |
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| Please type your signature here:
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| How did you hear about us?:
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| If referred, who referred you?:
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BA criminal background check and DMV report is required for all volunteers. You will be contacted in person to give your social security number. By pressing the submit button below, I certify that I have completed this application to the best of my knowledge and ability.
I certify that the above information is true, complete and accurate. Falsification of information is grounds for dismissal. I also understand that I am giving permission to Botetourt County to run a criminal background check and DMV report.
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