Action Center / Amherst County Fire and EMS Agencies Application for Volunteer Membership / / Amherst County, VA

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Amherst County Fire and EMS Agencies Application for Volunteer Membership

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THIS APPLICATION IS NOT ACTIVE. To Fill out a volunteer application, please contact Public Safety.

Dear Applicant:

You must be 16 years or older to volunteer with these organizations. Please complete all sections of this application. This application should not be construed as a contract. Volunteer service with any Amherst County volunteer agency or department is at will and may be terminated at any time with or without notice and with or without cause. This application involves volunteer service only and does not create or confer any employment rights on the volunteer. The County of Amherst expressly disclaims any employment obligations whatsoever for volunteers accepted into service.

* Denotes a required field

Personal Information

Please mark the agency you are interested in providing volunteer service with:*

Name*

Physical Address

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Mailing address if different from above.

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Operator's License Number

Date of Birth*

Home Phone Number

Phone Area Code-Phone 3-Phone 4 ext Extension

Cell Phone Number

Phone Area Code-Phone 3-Phone 4 ext Extension

Work Phone Number

Phone Area Code-Phone 3-Phone 4 ext Extension

Email Address*

Employment Information: (list most recent employer first).

Employer Name*

Dates of Employment*

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Title*

Imediate Supervisor's Name*

Responsibilities*

Reason for leaving*

Employer Name

Dates of Employement

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Phone Number

Phone Area Code-Phone 3-Phone 4 ext Extension

Title

Imediate Supervisor's Name

Responsibilities

Reason for leaving.

Education

Elementary School

School Name*

Grade Completed

Middle School

School name*

High School

School Name*

Last Grade Completed*

College +

Name of College Attend for Undergraduate Degree

Years Completed

Degree Earned/Field of Study

Name of college attended for Graduate Studies.

Number of years completed

Degree Earned/Field of Study

Fire, Rescue, EMS, Emergency Management Certifications/Training/Experience

Certification

Certificying State/Department/Agency

Expiration Date

Certification

Certifying State/Department/Agency

Expiration Date

Certfication

Certifying State/Department/Agency

Expiration Date

General Information

Are you presently or have you ever been a member of any fire, rescue·, EMS, or emergency services agency?*

If so, list agency, dates and contact information.

Have you ever been denied membership, had disciplinary action taken against you, or been asked to resign by any organization or emergency services agency?*

Please Do Not Complete The Following Field

If you answered yes, explain in detail. Be sure to include the name and address of the organization.

Do you have any physical defects or have you sustained·any injuries which may temporarily or permanently limit, restrict, or prevent you from performinng certain kinds of work?*

If yes, describe such defects and specific work limitation.

Have you been treated for-a physical illness in the past 5 years?*

If yes, please explain.

Have you ever been treated for a mental illness.*

If yes, please explain.

Do you take medication regularly.*

If yes, please explain.

Have you ever been convicted of any crime or traffic offense? Include misdemeanors, traffic offenses, and/or felonies.*

If yes, explain fully, giving dates, circumstances and final disposition. Discussion of criminal history may be necessary with the membership.*

Do you consent to a search of conviction information from your local, state, and national criminal history files?*

Do you have a valid driver's license?*

State Lisence was issued:

License Number:

Expiration Date:

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Amherst County, Virginia

Action Center

Amherst County Fire and EMS Agencies Application for Volunteer Membership

Personal Information

Employment Information: (list most recent employer first).

Education

Elementary School

Middle School

High School

College +

Fire, Rescue, EMS, Emergency Management Certifications/Training/Experience

General Information

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