Use the form below to apply for membership to the Black Rock Volunteer Fire Company. After completing this form, a representative of the membership committee will contact you. In the meantime, feel free to come down and visit the station. If you have any additional questions, please feel free to email membership@brvfc.org. Remember, no experience required! This form is also not a comitment to membership, our membership team will reach out to you and answer any questions you might have. We look forward to your application and would enjoy the opportunity to welcome you as a member of our team.

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Contact Information
Date Submitted:		12/02/2024 1738
First Name:
Last Name:
Date of Birth:
Social Security Number: Full or last 4
Gender:		Male Female
Phone #:
Address 1:
Address 2:
City, State, Zip:
Email Address:
Drivers License Number and Class:
Has your driver's license ever been suspended?:		Select Below Yes No
If your license HAS been suspended please explain the circumstances.: If not applicable type N/A
Education:		High School Diploma/GED Some College < 1 year Some College > 1 year Associate degree Bachelor's degree Master's degree
Occupation- Current Employer:
References (3): Name, Phone Number, Relationship, Years Known
Tell us about yourself:
Have you ever been convicted of a crime?:		Select Below Yes No
If you HAVE been convicted of a crime please describe the circumstances.: If not applicable type N/A
Prior Training
Prior Firefighter Training?:		Yes No
Prior Training:		None Firefighter I Firefighter II Hazardous Materials Operations Vehicle Rescue Technician Water Rescue Awareness Water Rescue Operations Current First Aid, CPR & AED Infectious Control, Bloodborne Pathogens Pump Operations Emergency Vehicle Operators Course NIMS 100 NIMS 700
Upload Certifications:		Add files...
Any other training or experience?:
Membership Type
What type of membership are you applying for?:		Firefighter Stipend Firefighter Junior Firefighter Fire Police Administrative General Support
Application Fee, Membership Dues:		Acknowledge $5.00 membership dues are payable at time of the applicant interview. Member dues are $5.00 payable annually and must be paid prior to the close of the January business meeting.
Documents Section
Resume and/or Cover Letter: Do you have a Resume and/or Cover Letter		YES NO
Resume/ Cover Letter: Attach a copy of your resume and/or cover letter if you have one.		Add files...
Emergency Contact Information
Name:
Relationship:
Home Phone:
Cellular Phone:
Email:
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