Please complete the interactive application for membership on the form below.  All information is maintained as confidential.  Once received, you will be contacted to schedule a face to face and informal meeting at the station.

TELL US ABOUT YOURSELF

Level of membership that I am applying for:   Active (normal) Support Honorary

Name:            Home Phone:  

Street:           City:        State:        Zip Code:  

Height:           Weight:        Gender:   Male Female    Hair Color:        Eye Color:  

DOB:             Driver License Number:        E-Mail:  

Can you driver an automobile:   Yes No      Can you swim:   Yes No   

Pleae list any special skills that you have: (EMT, SCUBA Diver, Computers, etc.)

List all Clubs and Organizations that you are a member of:

Have you been convicted of a felony or misdemeanor in the past five years:   Yes No   If yes, please explain below

Is your physical capacity for service as an active member limited in anyway:   Yes No   If yes, please explain below

TELL US ABOUT YOUR EDUCATION

Grade School:        Years Completed:        Diploma/Degree:   Yes No

High School:           Years Completed:        Diploma/Degree:   Yes No

College:                   Years Completed:        Diploma/Degree:   Yes No

EMT Certification Number:  

 I HEREBY DECLARE THE INFORMATION PROVIDED BY ME IN THIS APPLICATION AS TRUE, CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE.  I UNDERSTAND THAT IF ACCEPTED FOR MEMBERSHIP.  ANY MISSTATEMENT OR OMISSION OF FACT ON THIS APPLICATION SHALL BE CONSIDERED CAUSE FOR DISMISSAL.

 I AUTHORIZE THE NEW MARTINSVILLE FIRE DEPARTMENT TO OBTAIN AN INVESTIGATIVE CONSUMER REPORT CONTAINING INFORMATION OBTAINED THROUGH A National Crime Information Check (NCIC) PERSONAL INTERVIEWS WITH MY NEIGHBORS, FRIENDS, AND ACQUAINTANCES.

 I HEREBY AUTHORIZE THE NEW MARTINSVILLE FIRE DEPARTMENT BOARD OF REVIEW, TO RELEASE TO THE MEMBERS OF THE NEW MARTINSVILLE VOLUNTEER FIRE DEPARTMENT, ANY INFORMATION OBTAINED DURING THE INTERVIEWING PROCESS, WHICH IS RELATED TO ANY CRIMINAL AND/OR TRAFFIC RECORDS WITHOUT ANY PREJUDICE OR LIABILITY ON THE NEW MARTINSVILLE FIRE VOLUNTEER FIRE DEPARTMENT.

By typing my name to the right, I agree to the above statement:        Date: