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| PERSONAL |
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| Membership Type:
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| Last Name:
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| First Name:
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| MI:
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| Birth Date:
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| E-mail Address:
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| Street Address:
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| City, State, Zip:
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| How long have you lived at this address?:
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| Home Phone:
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| Business Phone:
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| Mobile Phone:
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| Sex:
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| Where are you currently employed?:
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| If you were in the Armed Forces, when were you discharged? Month/Year:
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| Are you over 18 years of age?:
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| Have you ever been convicted of a traffic violation, misdemeanor, or a felony:
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| If Yes, indicate the date and nature of the charge, police agency, court and disposition.:
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| PARENTAL INFORMATION (Required For Junior Membership) |
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| Parents Name:
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| Parents Phone Number 1:
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| Parents Phone Number 2:
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| EXPERIENCE |
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| Have you ever filed an application Lexington Park Volunteer Rescue Squad?:
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| If so, when?:
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| Have you ever been denied membership to a fire and/or rescue squad?:
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| If you have been denied membership, please give details:
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| Have you ever been discharged for misconduct or unsatisfactory service or asked to resign from a fire and/or rescue department?:
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| If you have been discharged for misconduct or unsatisfactory service or asked to resign please give details:
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List any fire fighting and/or emergency medical certifications that are current:
Please list certifications and state certified from
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| Please provide copies of certifications:
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| EDUCATION |
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| High School attended:
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| High School Location (City/State):
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| Did you graduate or receive a GED?:
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| Date graduated, or received GED:
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College or University:
Please list name, Location (City/State), Dates attended, Major or Degree awarded
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| REFERENCES |
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Reference #1 (Name, Address & Phone Number):
Please list reference, not related to you by blood, adoption, or marriage, which you have known for at least one year. References should not be members of the Lexington Park Volunteer Rescue Squad.
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Reference #2 (Name, Address & Phone Number):
Please list reference, not related to you by blood, adoption, or marriage, which you have known for at least one year. References should not be members of the Lexington Park Volunteer Rescue Squad.
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Reference #3 (Name, Address & Phone Number):
Please list reference, not related to you by blood, adoption, or marriage, which you have known for at least one year. References should not be members of the Lexington Park Volunteer Rescue Squad.
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Please provide any previous fire departments or rescue squads that you have been a member of:
DEPARTMENT, ADDRESS, CHIEF OFFICER, PHONE NUMBER
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| If applying for Junior Membership (Age 16 & 17), please attach most recent report card (If still in High School):
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| Drivers License #:
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| State Issued:
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| ACKNOWLEDGEMENT |
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Please type your signature here:
See Acknowledgement Statement below
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| Whom may we thank for referring you?:
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Acknowledgement Statement
By signing above, I signify that I have applied for the membership to the Lexington Park Volunteer Rescue Squad; that I have answered all questions truthfully and to the best of my knowledge; and that I fully understand that any intentional false statement may be grounds for dismissal from the department. Furthermore, I hereby grant to the Lexington Park Volunteer Rescue Squad permission to contact my employer, references, and any other persons or agencies who may have knowledge of me, my skills and my experience as may be deemed necessary.
Submission of this form also authorizes Lexington Park Volunteer Rescue Squad to obtain information regarding myself. This includes the following:
- Criminal background records/information
- Sex Offender Registry Checks
- Addresses
I, the undersigned, authorize this information to be obtained either in writing or via telephone in connection with my application. Any person, firm or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information will be held in confidence in accordance with St. Mary's County guidelines. If you have any questions please contact membership@lpvrs.org.
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