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2. Making false statements on this application will disqualify this application
   and you from applying within our agency for a period up to one year!

   Please Note: Virginia Office of EMS (OEMS) requires all applicants after January 1, 2013 to be fingerprinted for their background check

4. Last Name *
5. First Name *
6. Middle Name or Initial*
7. Birth Date*
   Birth Date
9. Street Address *
10. City*
11. State*
12. Zip*
14. Home Phone*
15. Cell Phone*
16. E-Mail Address*
18. Gender *
    -- Select One --Male Female
19. Race*
    -- Select One --American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderTwo or More Races White
21. Do you have a valid "Virginia" driver’s license?*

    1. Yes
    2. No
22. Attach Virginia License*
23. Please submit a copy of your driver’s transcript from the driver’s license issuing state.
24. Release of Information Form
    Release of Information Form (PDF)

    You MUST complete and submit this form before your application will be processed.
26. Have you ever been convicted of any law violation including a misdemeanor or felony?*

    1. Yes
    2. No
27. If Yes, Explain
29. Have you ever been convicted of any traffic violation?*

    1. Yes
    2. No
30. If Yes, Explain
32. Previous Emergency Services Experience*
34. Certification Levels & Training
35. Upload a copy of certification certificate
37. List any applicable physical, mental or emotional disadvantages*
38. Please choose the agency that you would like to volunteer with.*
    -- Select One --Boones Mill Fire Department Burnt Chimney Fire Department Callaway Fire Department Callaway RescueCool Branch Fire Department Cool Branch Rescue FCDPS CadreFerrum Fire DepartmentFerrum Rescue Fork Mountain Fire Department Fork Mountain Rescue Franklin County Rescue (Driver's Only)Glade Hill Fire Department Glade Hill Rescue Henry Fire Department Red Valley Rescue Scruggs Fire Department Scruggs Rescue Snow Creek Fire Department Snow Creek Rescue Special Operations Teams
40. Are you under the age of 18?*

    1. Yes
    2. No
41. Parent Liability Form
    Parent Liability Form (PDF)

    You MUST print, complete and submit the Parent Liability Form before your application will be processed.
43. BY TYPING or SIGNING YOUR NAME, YOU ARE CERTIFYING THAT YOU HAVE READ AND AGREE WITH THE FOLLOWING STATEMENT IN ITS ENTIRETY.*

    I agree that my typed name on this document is the legally binding equivalent to my handwritten signature, and that the information provided is true and accurate to the best of my knowledge and is a complete record. I authorize the Department of Public Safety to investigate my criminal and motor vehicle operation background to verify the information is correct.

    1. I agree.
45. Electronic Signature*
46. Date*
    Date
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field