Antioch Volunteer Fire Department | Volunteer Application

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Application for Membership

Please complete the information below, then select "Submit My Application" at the bottom of the page.

There are serious errors in your form submission, please see below for details.

Area(s) of Interest

Fire/Rescue

First Responder

Cadet

Office/Administrative

Tell Us About Yourself

Full Name:	Address:

City:	State:	Zip

Home phone:	Mobile phone:	Date of Birth:

Email address:

Tell Us About Your Experience

Do you have any previous experience in the Fire/Rescue or medical field? Yes No

If yes, please explain:

Do You Have A Felony Conviction

Have you ever been convicted of a felony? Yes No

How Is Your Driving Record

Do you have a valid driver's license? Yes No

If yes, state of issue:

How Is Your Health

Do you have any physical impairments which would prevent you from performing the duties applied for? Yes No

When Can You Respond To Calls

When would you normally be able to respond to emergency calls?

Day Evening Weekends Other (Explain below)

Emergency Contact

In case of emergency, please notify:

Name:		Address:

Relation:		Home Phone:

Mobile phone:		Other:

Personal References

List three personal references other than relatives not living with you:

Name:		Address:
Phone:

Name:		Address:
Phone:

Name:		Address:
Phone:

Cadets And Applicants Under 18 Years Of Age - Parent Or Guardian Approval Is Required

Name of Parent or Guardian:		Best time to contact:

Phone:

Terms and Conditions

By selecting "Submit My Application" and submitting this application for membership to Antioch Volunteer Fire Department, I hereby agree that all of the information contained in this application is true and correct, to the best of my knowledge. I understand that Antioch Volunteer Fire Department reserves the right to accept or deny my application for membership, as all applications must be reviewed and approved by the Board of Directors prior to acceptance.

All information provided in this application remains confidential and secure within the Antioch Volunteer Fire Department Board of Directors

I agree to the above terms and conditions.

Application for Membership

There are serious errors in your form submission, please see below for details.

There are serious errors in your form submission, please see details above the form!