APPLICATION FOR MEMBERSHIP
 

How long have you lived at your present address?

How long did you live at your previous address?

Have you ever been convicted of a felony or misdemeanor?

Felony or Misdemeanor Conviction

Do you have a high school diploma or equivalency diploma (GED)?

Did you attend any educational institution post high school?

Diploma or GED
Post High School Education

Are you a veteran of the US Military?

Military Veteran

Current Employer

Job Title

OK to Contact?

Can we contact?

Date Employed

Duties

Previous Employer

Job Title

OK to Contact?

Can we contact previous?

Start Date

End Date

Were you terminated?

Terminated Previously?

Previous Employment Duties

Do you have any previous fire department or emergency service experience?

Previous Experience?

EMS Certification Number (If Applicable)

Initial Certification Date

Certification Expiration Date

Do you have, or have you ever had, any of the following conditions: heart conditions, diabetes, high blood pressure, epilepsy or seizures in general, back injury, a job related injury, permanent disability?

Previous Medical Conditions?

Do you agree to have a physical exam performed by a licensed physician at no cost to you?

Are you currently receiving workers compensation due to a workplace injury?

Agree To Physical Exam?
Receiving Workers Comp?

How would you describe your current health?

Current Health?

List four (4) references that are not employers or relatives

List any special skills

List any machinery that you are qualified to operate

Why do you want to join the Elberta Volunteer Fire Department?

Use the Upload File button below to send a picture of your drivers license

Upload File

Information provided in this application will be used to perform a preliminary background and criminal history check. 

Thank you for your interest. Your application has been submitted! You will be contacted within the next few days.