Membership Application

It is fully understood that the foregoing information on this application for membership in the Buchanan Valley Volunteer Fire Department, Inc is true and correct to the best of my ability and knowledge. I grant the proper authorities of the Buchanan Valley Volunteer Fire Department Inc to confirm all information contained in this application for the sole purpose of approving or rejecting my request for membership. I understand that Buchanan Valley Volunteer Fire Department Inc will conduct a criminal background check upon receipt of my payment for same. I further understand that any information found to be incorrect may cause my application and/or membership to be cancelled so long as I live I further understand that if this application for membership is rejected it will be necessary for me to wait a period of one (1) year from the date of rejection before I may submit another application for membership. I agree to abide by the constitution, by-laws, and all other rules of it officers. All information contained in this application for membership in the Buchanan Valley Volunteer Fire Department Inc will be held in strict confidence.

Indicates Required Field

Name (First, Middle, Last)

Address

Street/Road Name, City, State, Zip Code

Home Phone Number

Cell Phone Number

Email Address

Driver's License Number

Date of Birth

Social Security Number

Sex

Select Below Male Female

Emergency Contact

Place of Employment

List Name of Employer and Phone Number if Applicable

Membership Class

Social Member (Must Live in the 1st due emergency response area) Associate Member (All other applicants) Firefighter Member (Must meet the requirements set forth by the Fire Chief) Junior Member (anyone ages 14-17)

Training Level

Training Level - Check those that Apply

Firefighter I Firefighter II EMT CPR EVOC NIMS

Special Skills

Example, Builder, Electrician, Computer Skills

Are you a member of any other fire department?

Select Below No Yes

If so, what department?

Has your membership ever been terminated from any other fire department?

Select Below YES NO N/A

Have you ever been convicted of any criminal activity in the past 5 years?

Select Below YES NO

Have you ever been convicted of a Felony?

Select Below Yes No

Reference (non-relative)

Name and Phone Number

Electronic Signature

Date Submitted

10/28/2026 2024

Sponsor Name

if applicable

All applications are considered for positions without regard to race, color, sex, religion, national origin, age, marital status or any other legally protected status.

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