Shenandoah County Online Volunteer Application Shenandoah County Online Volunteer Application Applicant InformationName: (First, middle, last)* Date of Birth:* SSN:* Phone/Cell Phone Number: Current Address:* City:* State:* Zip Code:* Email: Driver's License #: Employer InformationCurrent Employer:* Employer Address: How long employed: Phone: Email: City: State: Zip Code: Position: Emergency ContactName:* Adress: Cell Phone:* City:* State: Zip Code: Relationship:* References1. Name and Phone Number:* 2. Name and Phone Number:* 3. Name and Phone Number: Educational Background:High School:* College: Post Graduate: Military Experience: Membership DetailsDepartment you would like to join:* Woodstock Rescue Squad (5) Toms Brook Fire Department (9) Woodstock Fire Department (12) Conicville Fire Department (13) Fort Valley Fire Department (14) Edinburg Fire Company (15) Star Tannery Fire Department (17) Orkney Springs Fire and Rescue (18) Mt. Jackson Rescue and Fire (21) New Market Fire and Rescue (23) Strasburg Rescue Squad (25) Strasburg Fire Department (51) Type of Membership Interested In Applying For: (select all that apply)* Active Firefighter Active EMT Associate/Administrative Member: Junior/Cadet Member: Auxillary Member: Other: Have You Previously Held a Membership With Another Department?* Yes No If yes, please provide the name of the organization: Special Skills/ExperienceSkills: Computer Skills Photography Fund Raising Public Relations Recruitment Public Speaking If other skill, please explain: Certified Firefighter/EMT? Firefighter EMT No EMT Certification Number: (If applicable) Line of Duty Death Act BenefitsVolunteer Status (Check One) Active Support Probationary Associate Active Driver Junior Lifetime Member on Leave Inactive Lifetime Inactive Observer/Ride-a-Long Volunteer Vehicle License Fee WaiverBy providing this information, you may be eligible for a waiver of registration fee. Vehicle must be registered in your name.Vehicle Year: Vehicle Make: Vehicle Model: Vehicle VIN: SignatureI 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.Consent* I agree to allowing my online signature to be used.Name* First Last Δ
