Application for Membership

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Athens Rural Fire - McMinn County Rescue Application for Membership

Name *

Address *

Phone Number *

Email Address *

How many years have you lived at this address? *

Date of Birth *

YYYY

Driver License Number (list class, expiration date, restrictions, endorsement) *

Highest Grade of School Completed *

Name of Last/Current School (Name, City, State) *

Highest or Current Grade Level *

Do you participate in any school activities? (If yes, please list)

Employer (Name, Address, Phone Number, Duties) *

Emergency Contact #1 (Name, Relation, Address, Phone) *

Emergency Contact #2 (Name, Relation, Address, Phone) *

List any chronic ailments, physical disabilities, or prolonged illnesses and dates

Family Physician (Name, Address, Phone)

Have you ever been arrested for any criminal activity? *

Yes

If yes, list the arresting agency, date,
nature of the incident, and the final disposition of the incident. DO NOT LIST MOTOR VEHICLE
VIOLATIONS.

Have you ever been or a current member or any other rescue squad, fire department, and or ambulance
organization? *

Yes

If yes, please list below the name of the organization(s), city & state, contact
information, and years or service.

List any service or civic organization to which you belonged or currently belong as a member. Please
include the dates you were a member.

Reference #1 (Name, Address, Phone) *

Reference #2 (Name, Address, Phone) *

Reference #3 (Name, Address, Phone) *

Submit

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