Membership Application

Today's Date

First Name *

Last Name *

Do you use a nickname, abbreviated name or any name other than your legal name? If so, please list:

Other Names:

E-mail *

Address 1 *

Address 2

City *

State *

Zip/Postal Code *

Country *

Date of Birth

Please list phone numbers in the order you would like us to use when contacting you, specifying which type of phone number: 

PH#

Type

PH#

Type

PH#

Type

How did you hear about PVRS?

If applicable, list the member(s) recruiting you:

What type of membership are you applying for?

Senior (18 years or older)
Junior (under 18)
Academic (over 18 and in school)
Administrative Support

Have you ever been a member of an EMS agency or Fire Department?

If so, when and where?

What is your membership status with that dept?

Do you have any training that will benefit you at PVRS? If so, please list:

Physical Address (if different than page 1):

Do you have a valid driver’s license?

License #:

State:

Issue Date:

Exp Date:

Have you ever been convicted of (a) moving traffic violation(s)? If so, please describe the offense

Date of Charge:

County/City/State of Conviction:

(for additional convictions please list on a separate piece of paper)

Have you ever been convicted of (a) violation(s) of law? If so, please describe the offense(s):

Date of Conviction:

Date of Charge:

County/City/State of Conviction:

(for additional convictions please list on a separate piece of paper)

Please list 3 character references not related to you or associated with PVRS. 

(1)Name:

PH#:

Relation:

Email Address:

(2)Name:

PH#:

Relation:

Email Address:

(3)Name:

PH#:

Relation:

Email Address:

I hereby certify that all entries on this application and attachments are true and complete. I understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture of membership with Purcellville Volunteer Rescue Squad, Inc (PVRS). I understand that all information on this application is subject to verification and I consent to a criminal history and driver background check. I also consent that PVRS may contact references listed in this application. I further authorize PVRS to verify and use, as it sees fit, any information received from such contacts.

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