The following information must be provided by or will be obtained on behalf of all applicants: 1. Social Security Number 2. Criminal History Check 3. OEMS Background Check 4. Report Card (if still in High School)
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| Personal Information |
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| Membership Type:
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| Last Name (Maiden):
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| First Name:
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| Middle:
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| Suffix:
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| Street Address:
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| City:
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| State:
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| Zip Code:
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| Email Address:
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| Phone Number:
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| Alternate Phone:
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| Marital Status:
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| Date of Birth:
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| Birthplace:
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| U.S. Citizen:
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| Last 4 Digits of Social Security Number:
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| Drivers License Number:
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| State Issued:
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| Have you ever been convicted of a traffic violation:
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| If yes, please explain the charge and disposition:
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| Have you ever been arrested, summoned into court as a defendant or indicted, convicted, fined, imprisoned, or placed on probation, or has any case been filed against you?:
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| If yes, please explain:
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| Education |
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| High School Attended (Name and Address):
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| Graduate:
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| If not, please list highest grade completed:
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| Higher Education (College or University, City/State, Dates Attended, Major or Degree Awarded):
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| Employment |
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| Present Employer (Please include Address, Phone Number, Immediate Supervisor and Occupation. If not employed, please type N/A):
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| Previous Employer (Include Address, Immediate Supervisors, Occupation. Please type N/A if no previous employer)):
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| Have you ever been forced to resign or dimissed from any position?:
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| Please explain if you answered yes:
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| Experience |
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| Have you ever been a member of a fire department, rescue squad, or similar organization?:
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| Name and Address of Organization (If none, please type N/A):
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| Date(s) of service (Please type N/A if not applicable):
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| Reason for leaving (Please type N/A if not applicable):
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| Please list any certifications you may hold:
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| Medical History |
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| Have you ever had an operation or been seriously injured?:
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| Explain if you answered yes:
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| Do you have any medical history we need to be aware of:
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| Please explain if you answered yes to previous question:
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| Do you wear glasses:
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| Any use of a hearing device:
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| References |
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| Please list three people who are not related to you by blood or marriage who are familiar with your education or work experience (Name, Complete Address, Telephone Number):
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| 1st Reference :
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| 2nd Reference:
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| 3rd Reference:
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| Additional |
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| In a brief paragraph, state why you wish to join this department, what the department can gain from your membership and what you expect to gain from membership:
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| If you were referred by a current Orange Volunteer Fire Company member, who can we thank for the reference:
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| The Orange Volunteer Fire Company does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status. |
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| Acknowledgement - I understand that I am applying to Orange Volunteer Fire Department located in Orange, VA:
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| Acknowledgement - I have answered all questions truthfully and to the best of your knowledge; and that you fully understand that any intentional false statement may be grounds for dismissal from the department.:
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*By submitting this application, you signify that you have applied for membership to the Orange Volunteer Fire Company; that you have answered all questions truthfully and to the best of your knowledge; and that you fully understand that any intentional false statement may be grounds for dismissal from the department. Furthermore, you hereby grant to the Orange Volunteer Fire Company permission to contact my employer, references, and any other persons or agencies who may have knowledge of you, your skills, and your experiences as may be deemed necessary.
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