DEPTFORD FIRE DEPARTMENT

Volunteer Firefighter
Membership Application

Battalion #:                                                     

Company Name:

DOB:     /       /     

Name:

SS #:

Address:

Town:

Phone # (H):

(W):

 
Occupation:  __________________________________      Work Hrs: ______to ______
Employer Name:  ________________________________________________________
Employer Address:   ______________________________________________________
Contact Person:  _______________________________       Phone #:   ______________

Health:      ____Excellent    ____Good    ____Fair    ____Poor

Blood Type:

Do you have any physical limitation, which would restrict your ability to perform firefighter duties?  (Circle)            Yes      No       (If yes, explain)
________________________________________________________________________
________________________________________________________________________

List pertinent medication and medical conditions:
________________________________________________________________________
________________________________________________________________________

Copy of last physical examination report attached?  (Circle)            Yes      No       

Driving Privileges:         Are your driving privileges revoked or have they ever been revoked?  (Circle) Yes      No       (If yes, explain)
________________________________________________________________________
________________________________________________________________________
Drivers License #:                        -                  -

List current membership in other organizations:
1.         ______________________________________________    Date Joined: _______
2.         ______________________________________________    Date Joined: _______
3.         ______________________________________________    Date Joined: _______

Previous Experience:
1.         ______________________________________________    Years There: _______
2.         ______________________________________________    Years There: _______
3.         ______________________________________________    Years There: _______