Butte Valley Fire Protection District
APPLICATION FOR MEMBERSHIP
Name: ______________________________ Date: ______________
(Please Print)
Address: ____________________________ Phone (H): ___________
______________________________ Phone (M): ___________
______________________________
Driver Lic. #:________________ S.S.#:_____________ Birthday:________________
Do you have any firefighting, rescue or medical experience? Y / N
(Not a requirement) If Yes explain what type of experience
Are you willing to come to training sessions or work days offered? Y / N
Are you certified in any of the following? (Circle one) Firefighter EMT 1st Responder CPR
Do you hold any instructors certificates? Y / N
Are you able to respond during the daytime? Y / N
Can you reach the station within 15 minutes while obeying traffic laws? Y / N
Are you available to respond on most nights and weekends? Y / N
Have you had any moving violation traffic tickets in last 3 years? Y / N If so explain
Have you ever been convicted of a felony offense? Y/N
Have you ever been a member of another volunteer fire department? Y / N
If yes, what department?_______________________________
Have ever been removed or resigned from another fire department? Y / N
If yes, what department?___________________ Reason?__________________
Do you have any medical or health problems, or a physical handicap that would prevent you preforming stressful and vigorous firefighting activities, i.e. blood pressure, heart problems, etc)? Y / N – If Yes there are still a need for support positions such as dispatch, fire preventions and other fire/rescue positions
In the event of an accident, injury or death, you realize that upon signing this application and you are accepted as a member, you are releasing the BVFPD and any officer or member of any further liability to you or your family. ___________ write in Yes or No
Do you understand that any false information on this application , or any willful misconduct, disregard for our written policies or the Standard Operation Guidelines, could lead to your being removed from the department? Y / N
IF ACCEPTED FOR MEMBERSHIP, YOU WILL BE ON A 6 MONTH PROBATION PERIOD
Applicant Signature