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2. Applicant Information
4. Name: (First, middle, last)*
6. Date of Birth*
   Date of Birth
8. Phone / Cell Phone Number
10. Current Address*
12. City*
13. State*
14. Zip Code*
16. Email
20. Membership Details
22. Department you would like to join*

    1. Woodstock Rescue Squad (5)
    2. Toms Brook Fire Department (9)
    3. Woodstock Fire Department (12)
    4. Conicville Fire Department (13)
    5. Fort Valley Fire Department (14)
    6. Edinburg Fire Company (15)
    7. Star Tannery Fire Department (17)
    8. Orkney Springs Fire and Rescue (18)
    9. Mt. Jackson Rescue and Fire (21)
    10. New Market Fire and Rescue (23)
    11. Strasburg Rescue Squad (25)
    12. Strasburg Fire Department (51)
24. Type of Membership Interested In Applying For: (select all that apply)

    1. Active Firefighter
    2. Active EMT
    3. Associate/Administrative Member
    4. Junior/Cadet Member
    5. Auxiliary Member
    6. Other
26. Have You Previously Held a Membership With Another Department?*

    1. Yes
    2. No
28. If yes, please provide the name of the organization
32. Certified Firefighter / EMT?

    1. Firefighter
    2. EMT
    3. No
34. EMT Certification Number: (If applicable)
38. How did you hear about us?

    1. Public Event
    2. Social Media
    3. School
    4. Signage
    5. Friends/Family
    6. Other
42. Signature

    I authorize the verification of the information provided on this as complete and accurate as possible. By E-signing below I authorize Shenandoah County Department of Fire and Rescue to conduct a background investigation in connection with my volunteer application. This investigation may include information as to school/work attendance, DMV records, employers, references and other appropriate sources. All information received by the Department will be used in accordance with applicable law.

44. Consent*

    1. I agree to allowing my online signature to be used.
46. First Name*
47. Last Name*
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field