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Please Fill Out the Information Below and Mail to:
Clifton Forge Rescue Squad
522 Commercial Avenue
Clifton Forge, VA 24422

Clifton Forge Rescue Squad

Application for Membership

Full Name                                       ___________                     Age                Date          ____          SSN        -       -            

Address                                                     _________________                   Telephone(H)                        (W)                       

Occupation                         __________                                     Work Schedule                                         _______                

Are you able to answer calls from work?    _       ( ) Yes  (  )  No         ________________       Married  (  ) Yes  (  ) No

Spouse's Name (if Yes)             ___________               # of Children           _______                 Ages                                  

Virginia Drivers License #                               _____________________________________________                                  

Reason for Requesting Membership-          ________________                                                                                            

                                                                                                ____________________                                                                 

Training and/or Experience-                 __________________                                                                                                  

                                                                              ____________________                                                                                   

Have you ever been convicted of a Felony or Misdemeanor, other than a parking ticket?  ______________ If yes,

Explain-                                                                                                                                ____________________                   

Have you ever been rejected or dismissed from any other organization?  __________     If yes, Explain-              

The undersigned, understand that my application will be placed under investigation by the rescue squad and
will be brought to the floor of the rescue squad at the following business meeting. The squad, as a whole,
will then vote on my application. Upon acceptance to the rescue squad, I will be placed under the
status of trainee member for 6 months and I will remain in this class until I complete and pass a Virginia EMT Program. Also, I know that as a trainee member I cannot run for office and do not have a vote. Upon
successful completion of the EMT program I will move up to Probationary Member and will serve a minimum
of 6 months in this class and will not have a vote and cannot run for office. I understand that I will take part in all squad activities that my health and availability permits, without sacrifice to my family, occupation, and or
home. I will conduct myself under the rules set forth by the Clifton Forge Rescue Squad and obey all
instructions and regulations to the best of my ability.

Applicants Signature                                                                                      _______________________                         

I have applied for membership in the Clifton Forge Rescue Squad, Inc. I authorize my family and
acquaintances to give any information they have concerning me to the membership committee and to the representatives of the rescue squad. I hereby release anybody who gives this information from any liability
that might otherwise result in termination of my application.

Applicants Signature                                                                        ______________________                                         

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Committee Use Only

Date Received__________ Date Investigated__________  Interviewed By_______________

Recommendation of Committee__________  Squad Vote Date__________  Accepted (  ) Yes  (  )  No